SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDITORIAL
VOLUME 7 NUMBER 4 • NOVEMBER 2010
135
Recent advances in the pharmacological management of
painful diabetic neuropathy: a South African perspective
and comment
Gillian Lamacraft
Introduction
P
ainful diabetic neuropathy (PDN) is an under-diagnosed and
under-treated condition
1
and it is appropriate that this journal
has reprinted Tesfaye and Selvarajah’s article on the treatment
of PDN.
2
The prevalence of diabetes in South Africa, currently
estimated at 3.9
3
to 9%,
4
will probably double in the next 20 years.
5
The country is passing through an economic and health transition,
which is resulting in a population more at risk for diabetes, i.e. older
and more overweight.
6,7
As the prevalence of diabetes increases, so
will the prevalence of PDN.
Obesity is affecting particularly black females,
8,4
of which there
are over 20 million in South Africa.
9
Adolescent girls are becoming
fatter and their fat distribution is often central, which is a risk factor
for the metabolic syndrome,
10
and it is also more likely in blacks
to lead to type 2 diabetes.
11
Education regarding weight control
is difficult as these girls frequently do not wish to be thinner,
associating fatness with affluence, and weight loss with illness and
HIV/AIDS.
12
Although studies in developed countries suggest that diabetic
peripheral neuropathy may be less common in those of African
descent compared to non-Hispanic whites (47 vs 37%),
13
in the
South African situation, ethnicity may be counteracted by social
circumstances (glycaemic control is often poor in rural areas
14
),
and it is not known whether there is a higher incidence of diabetic
neuropathy in the black population or whether the incidence of
PDN in those with neuropathy (approximately 1/3
15
) varies with
ethnicity.
Treatment of PDN in South Africa
Tesfaye and Selvarajah
2
carefully explain the range of drugs
available for the treatment of PDN and in which order they should
be tried, taking into account efficacy, adverse effects and costs.
These authors are based in the UK and while most of these drugs
are available in South Africa, not all are. Some are available only to
private practitioners and some may be prescribed in public hospitals
only by specialists or named specialists (Tables 1, 2).
First-line treatment
Tesfaye and Selvarajah concluded that the first-line treatment
is with a tricyclic antidepressant (TCA), a selective serotonin
noradrenaline reuptake inhibitor (SNRI) (e.g. duloxetine) or an
anticonvulsant (e.g. pregabalin or gabapentin), taking into account
patient co-morbidities and cost.
2
They also note that it is not known
which of these drugs is most efficacious, and that NICE guidelines
16
recommend a TCA being used first. Hence the TCA, amitryptilline,
is most appropriate for the first-line treatment of PDN in South
Correspondence to: Gillian Lamacraft
Associate Professor of Anaesthesiology and Head: Pain Management Unit,
Universitas Academic Hospital Complex, Bloemfontein
Tel: +27 (0) 51 405-3613
e-mail:
S Afr J Diabetes Vasc Dis
2010;
7
: 135–137.
Table 1.
Drugs available in the Free State for the treatment of PDN
Drugs to treat
PDN
One oral
dose
Cost (Rand)
On Free
State
essential-
drug list?
Prescriber
restriction
code
One
dose
Daily
Amitryptilline*
10 mg 0.16 0.16 (od)
Yes
14
Amitryptilline
25 mg 0.10 0.10 (od)
Yes
14
Duloxetine*
(Cymbalta
®
)
60 mg 8.86 8.89 (od)
No
N/A
Gabapentin*
(Epleptin
®
)
100 mg 0.49 1.47 (tds)
Yes
5
Gabapentin
300 mg 1.51 4.53 (tds)
Yes
5
Gabapentin
400 mg 3.72 11.16 (tds)
No
N/A
Pregabalin
(Lyrica®)*
150 mg 10.70
†
21.4 (bd)
No
N/A
Tramadol*
50 mg 0.23 0.69 (tds)
Yes
4
Tramal SR
®
100 mg 10.15 20.3(bd)
No
N/A
Tramal SR
®
150 mg 10.19 20.38 (bd)
No
N/A
Tramacet
®
37.5/325 3.23 9.69 (tds)
No
N/A
Morphine SR*
10 mg 0.91 1.82 (bd)
Yes
2
Morphine SR*
30 mg 1.69 3.38 (bd)
Yes
2
Sloan’s Heat Rub
(contains capsicum)
One tube 22.48
per tube
No
N/A
Lignocaine gel 2% 20 ml
22.32
per tube
Yes
10
α
-lipoic acid*
300 mg 4.55 9.10 (bd)
No
N/A
Carbamazepine CR 200 mg 0.68 1.36 (bd)
Yes
14
Carbamazepine CR 400 mg 0.99 1.98 (bd)
Yes
14
Paracetamol
500 mg 0.03
0.24
(2 tabs qds)
Yes
10
Paracetamol
+
codeine
500 +
8 mg
0.14
1.12
(2 tabs qds)
Yes
12
*Drugs cited in article by Tesfaye and Selvarajah.
2
†
The cost of drugs available only privately in the Free State may be cheaper in other
provinces, where they are available in the public health system, e.g. the cost of
pregabalin to the public healthcare system has been recently quoted as R2.23.
