Painful Diabetic Neuropathy Guidance Released by American Academy of Neurology

Brian Callaghan, MD, MS

The American Academy of Neurology (AAN) has released new guidance detailing optimal pharmacologic and nonpharmacologic management of painful diabetic neuropathy, the organization’s first update since their 2011 guideline recommendations.

Aimed at helping neurologists and other care providers determine the best treatment for patients with diabetic neuropathy, the AAN guideline provides an overview of oral and topical treatments for painful diabetic neuropathy and also details factors for clinicians to consider before presiding an initial treatment, such as the presence of mood or sleep disorders.

“Living with pain can greatly affect a person’s quality of life, so this guideline aims to help neurologists and other doctors provide the highest quality patient care based on the latest evidence,” said guideline author Brian C. Callaghan, MD, MS, of the University of Michigan in Ann Arbor and a Fellow of the AAN, in a statement. “Painful diabetic neuropathy is very common, so people with diabetes who have nerve pain should discuss it with their doctor because treatment may help.”

Released on December 27, 2021, the guideline was composed by Callaghan and other members of the AAN Guideline Subcommittee, which included 18 members from multiple institutions from the US and abroad. A 14-page document citing more than 60 references, the new recommendations are based on a literature review encompassing data published from January 2008 to April 2020.

Among the highlights included in the AAN release is the recommendations against using opioids as a treatment option for diabetic nerve pain. The guideline recommends and lists multiple oral and topical medications considered effective at reducing nerve pain, according to the literature review.

The guidelines recommend tricyclic antidepressants (TCAs) serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentinoids, and sodium channel blockers. TCAs mentioned in the guideline include amitriptyline, nortriptyline, and imipramine, SNRIs included were duloxetine, venlafaxine or desvenlafaxine, gabapentinoids included gabapentin or pregabalin, and sodium channel blockers included carbamazepine, oxcarbazepine, lamotrigine, or lacosamide.

“New studies on sodium channel blockers published since the last guideline have resulted in these drugs now being recommended and considered as effective at providing pain relief as the other drug classes recommended in this guideline,” Callaghan added.

Guideline authors point out clinicians should determine if a person has mood or sleep problems before prescribing a treatment for painful diabetic neuropathy. The guideline also includes multiple other Level B recommendations. These include recommendations for offering patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class. Of note, the recommendations against opioids for treatment, recommending TCAs, SNRIs, gabapentinoids, or sodium channel blocks, and assessing for sleep or mood disorders were also given Level B recommendations.

“It is important to note that the recommended drugs and topical treatments in this guideline may not eliminate pain, but they have been shown to reduce pain,” said Callaghan. “The good news is there are many treatment options for painful diabetic neuropathy, so a treatment plan can be tailored specifically to each person living with this condition.”

This guideline, “Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary,” was published in Neurology.