A Closer Look At Pharmacologic Compounds For Painful Diabetic Peripheral Neuropathy

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Author(s): 
Andrew H. Rice, DPM, FACFAS, and Sarah Edgar, DPM

   Dr. Rice is an Assistant Clinical Professor in the Department of Orthopedics and Rehabilitation at Yale University School of Medicine. He is in private practice at Fairfield County Foot Surgeons in Norwalk, Conn. He is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Edgar is the Chief Resident of Podiatric Medicine and Surgery at Yale-New Haven Hospital in New Haven, Conn.

References

1. Muthuraman A, Singh N, Jaggi AS, Ramesh M. Drug therapy of neuropathic pain: current developtments and future perspectives. Curr Drug Targets 2013 Oct 3 (Epub ahead of print).
2. Anitescu M, Benzon H, Argoff C. Advances in topical analgesics. Curr Opinion in Anaesthesiology. 2013; 26(5):555-561
3. Mick G, Baron R, Finnerup NB, et al. What is localized neuropathic pain? A first proposal to characterize and define a widely used term. Pain Manage 2012; 2:71-77.
4. Argoff CR. Topical analgesics in the management of acute and chronic pain. Mayo Clin Proc 2013; 88(2):195-205.
5. Mahoney JM, Vardaxis V. Topical ketamine cream in the treatment of painful diabetic neuropathy: randomized placebo-controlled, double-blind initial study. J Am Podiatr Med Assoc. 2012; 102(3):178-183.
6. Lynch ME. Topical 2% amitriptyline and 1% ketamine in neuropathic pain syndromes: randomized, double-blind, placebo-controlled trial. Anesthesiology 2005; 103(1):140-146.

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DrDPMsays: February 10, 2014 at 10:19 pm

There are podiatrists who now use low dose bupivacaine (local anesthetic) in the form of ankle blocks to treat somatic sensory peripheral neuropathy in the feet. It is administered twice weekly for 2 to 2,5 months. Excellent symptomatic treatment. Low dose bupivacaine acts as an analgesic by inhibiting over expressed over active sodium ion channels in axons of neuropathic somatic sensory peripheral nerves. It is these overactive overexpressed sodium ion channels that create sub-threshold oscillation membrane potentials that are the spontaneous aberrant electrical signals that are transmitted to the somatosensory cortex of the brain, which then manifest as the somatic sensory symptoms of burning, pins and needles, and tingling in the feet as well as numbness. Low dose bupivacaine ankle blocks are used in conjunction with EST (electrical signal treatment) and with TENS (transcutaneous electrical nerve stimulation) unit, generating excellent symptomatic relief from somatic sensory neuropathy.

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DrDPMsays: February 10, 2014 at 10:25 pm

Combination treatment (i.e. oral Lyrica + cutaneous Lidoderm Patches + low dose bupivacaine nerve blocks) is the best way to treat somatic sensory peripheral neuropathy in the feet. Such combination treatment is symptomatic treatment, not a cure, that the neuropathy patient needs for life as needed.

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Podiatrist PAsays: February 12, 2014 at 10:23 am

More placebo double blind studies (randomized control trials) are needed with these topical medications. The two RCTs published so far revealed that there is no medical evidence that these topical medications actually are medically necessary in treating neuropathy in the feet. There should be about 10 more published RCTs required to ascertain whether these topical medications are medically necessary or not. It is still premature to know for now with only two RCTs published.

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