Glove and Stocking Pain: Hallmark of Peripheral Neuropathy
Half of people who have diabetes eventually develop diabetic peripheral neuropathy, and the warning signs are sensory symptoms that start in the distant periphery and progressing in a characteristic 'glove and stocking' way.
People who have diabetes fear diabetic peripheral neuropathy (DPN), as it is common and the chance of developing this painful condition increases as disease duration increases. Half of people who have diabetes eventually develop DPN, and the warning signs are sensory symptoms that start in the distant periphery and progressing in a characteristic 'glove and stocking' way. In addition to causing unremitting pain, DPN is also associated with increased mortality. Patients often have difficulty sleeping, struggle to maintain a positive outlook, and are often unable to complete activities of daily living.
The journal Clinical Therapeutics has published a critical review on this topic that includes seminal and novel research in epidemiology, and offers insight into diagnosis of this common condition. Of great interest to pharmacists is their review of emerging pharmacotherapies.
The authors begin by pointing out the clinicians often misdiagnose DPN, and consequently, fail to treat as aggressively and effectively as they could. The cornerstone of treatment is actually prevention, meaning that clinicians need to work with patients to achieve tight glycemic control.
The American Association of Clinical Endocrinologists, American Academy of Neurology, European Federation of Neurological Societies, National Institute of Clinical Excellence (from the United Kingdom), and the American Diabetes Association have published guidelines to help clinicians manage DPN.
Once DPN develops, management of associated pain depends on individualized treatment plans. Creating these plans is often difficult. Clinicians generally start with monotherapy with duloxetine and pregabalin (drugs of choice), but progress to combination therapies. Many patients respond poorly regardless. Trials of venlafaxine, oxcarbazepine, tricyclic antidepressants, atypical opioids (tramadol and tapentadol), and botulinum toxin may be necessary. A strength of this article is a table covering these agents and their dose ranges as recommended by the various guidelines.
The FDA has not approved any new treatment for DPN for 2 decades. Some of them are from the tried-and-true drug classes using different doses or schedules, while others are new entities. The bottom-line message from this review is that all clinicians need to watch for DPN in their diabetic patients, and treat early.
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Iqbal Z, Azmi S, Yadav R, et al. Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy. Clin Ther. 2018 Apr 27. pii: S0149-2918(18)30140-1. doi: 10.1016/j.clinthera.2018.04.001. [Epub ahead of print]