Recent Advances in Management of Painful Diabetic Neuropathy

Painful diabetic neuropathy are common and present a major challenge to the practicing physician. Pain is universal symptom in patients with rare acute sensory neuropathy and is present in only upto 50% of those patients with the common chronic sensory motor neuropathy. The first step in symptom management is to stabilize glycemic control. There is increasing evidence that blood glucose flux may exacerbate neuropathic pain, so avoiding swings of glycemia from hypoglycemia may help. It is possible that hyperglycemia and its consequent biochemical features may directly cause neuropathic pain. Other theories of the genesis of pain in diabetes include the presence of spontaneous electrical activity in diseased distal axone and also the possibility of ephaptic transmission between efferent autonomic fibers and afferent nociceptive fibers. The approach should be to exclude all non-diabetic causes, remembering that diabetic neuropathy is a diagnosis of exclusion of other potential pathologies. Glycemic control should be assessed particularly looking at A1c and blood glucose profiles. All treatments for painful neuropathy target the symptoms rather than the underline pathophysiologic abnormalities. All potential treatments have side effects, and these should be discussed with the patients. First line agents in many centers remain the tricyclic antidepressants, which should be taken at night. Side effect are common; however, the tricyclic agents, specially those with the anticholinergic effect cause symptoms, such as dry mouth and urinary retention. The use of antiarrhythmics, such as maxiletine, has generally been disappointing. Thus anticonvulsant drugs such as gabapentin have been the main stay of management. Among the other listed drugs, tramadol has also been shown to be efficacious in the management of neuropathic pain.