CURRENT TOPICS
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VOLUME 7 NUMBER 4 • NOVEMBER 2010
these measures the assistance of a chronic pain management
service, following a discussion with the patient, is recommended.
Conclusions
Painful DPN is a significant clinical problem affecting 10–20% of
all diabetic patients. Despite this it continues to be underdiagnosed
and under-treated, and this unsatisfactory scenario must change.
The minimum requirements for diagnosis of painful DPN are
assessment of symptoms and neurological examination, with shoes
and sock removed. Bilateral sensory impairment is almost always
present. First-line therapies for painful DPN are a TCA, a SNRI
(such as duloxetine) or an anticonvulsant (such as pregabalin or
abapentin), taking into account patient co-morbidities and cost.
32
As TCAs are considerably cheaper, NICE has recommended that
they should be used as first-line treatment. Combination therapy
may be useful but further research is required. Direct head-to-head
comparative trials are also required as are long-term studies on the
efficacy of drugs, as most trials have lasted less than 16 weeks.
34
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Key messages
• Painful diabetic peripheral neuropathy affects up to one
in five patients
• Active questioning and examination are important
because patients may not complain of the symptoms
• NICE guidelines for pharmacological therapy:
first line – tricyclic anti-depressants amitriptyline
second line – serotonin noradrenaline reuptake
inhibitors, eg duloxetine, or anticonvulsants, eg
gabapentin or pregabalin
third line – opiate analgesics
• Combination of low doses of agents may be more
efficacious with fewer side effects than a high dose of a
single therapy
