Current And Emerging Insights On Treating Diabetic Peripheral Neuropathy

Start Page: 36
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Author(s): 
Peter Bregman, DPM, FAENS, FACFAS, and Pasquale Cancelliere, DPM

   Instrumentation is also of importance. Bipolar cautery and at least 3.5x loupe magnification is mandatory. One must also realize the importance of exploring all possible areas of potential compression during any surgery. It is also important never to immobilize the foot or leg after surgery as this can lead to scar entrapment and fibrosis. Now with the advent of new tissue grafts, we will often utilize amniotic based products such as Amniocare™ (Applied Biologics) to avoid any scarring and enhance healing. When necessary, one must be able to perform an internal neurolysis if there is damage to the fascicles. However, in general, it is best to avoid handling of any nerve as much as possible.

   Once the surgery is complete, it is important to get the patient ambulating as soon as possible in order to avoid adhesions and excessive scarring to the decompressed nerve. In general, our success rate is around 85 percent for most of the nerves in the lower extremity.

What You Should Know About Pharmacological Treatment Options

Utilizing topical custom pharmaceuticals plays an important role in the management of neuropathy and newer delivery vehicles are helping get the medication to the specific area needing treatment. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of pain associated with a variety of indications, including arthritic conditions, but their usefulness is often limited by dose-dependent adverse events, such as gastrointestinal disturbances, cardiovascular events and renal toxicity. Topical formulations offer the potential to deliver analgesic concentrations locally at the site of inflammation while minimizing systemic concentrations, which lowers that risk of side effects.15

   The most commonly used topical medications in the treatment of neuropathy are: gabapentin (Neurontin, Pfizer) ketamine, cyclobenzaprine (Flexeril), amitriptyline (Elavil, Pfizer), fluribiprofen (Ansaid, Pfizer) and ketoprofen (Orudis) along with a local anesthetic such as lidocaine or prilocaine.

   Oral medications can play an important role in the successful treatment of diabetic peripheral neuropathy but are not a cure. We have been inundated by pharmaceutical reps who have extolled the virtues of their particular company’s drug for the treatment of neuropathy. We are told this is the latest and greatest “super pill.” We can all think of a few drugs that we have tried and had high hopes for but ultimately they just made money for the companies without really helping our patients. Before initiating any pharmacologic protocol for your patients, you need to assess them properly, make sure you properly prescribe the drug and monitor its use.

   The lead author has seen many patients who are taking gabapentin but not taking it properly. It is a very safe drug and can work well when one administers it properly. Be sure to titrate the drug very slowly. One can give it safely in doses up to 3,200 mg/day or more. The lead author sees too many people taking less than 900 mg a day and they have no relief of symptoms. Then they think the drug does not work. Also, some of them have taken the drug improperly, taking too much too soon and subsequently giving up on the drug because “it did not work.”

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