Current And Emerging Insights On Treating Diabetic Peripheral Neuropathy

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

   Amitriptyline is another drug that patients can use but it often has undesirable side effects such as tachycardia and dry mouth. Use this with care in patients with heart disease and depression. However, desipramine, which is in the same class of drugs, has fewer side effects and works just as well if not better in my experience. It is also less expensive than any of the other drugs available. One can prescribe amitriptyline at up to 150 mg/day and ensure titrating the drug up in dosage. The lead author usually uses this as a first-line drug for patients needing pharmacotherapy. The lead author starts at 50 mg/day and increases by 10 to 20 mg every five days or so. You can adjust this to the patient’s needs. You will want to check levels of the drug every three months or so to make sure patients are not getting toxic levels. This is rare but it can lead to cardiac problems so you may want to check the electrocardiogram.

   Research has shown that topiramate (Topamax, Janssen Pharmaceuticals) can be beneficial in treating small fiber neuropathy as it may help in the regeneration of the small nerve fibers that are damaged with small fiber neuropathy the disease.16

   Duloxetine (Cymbalta, Eli Lilly) is also a drug that the lead author likes to use. It has shown good efficacy in the treatment of neuropathy but it also has an anti-depression indication. Most people suffering from chronic pain are suffering from depression and we think it is important to address this factor as well.17 Depression is a very debilitating disease and can affect your whole treatment plan.

   One can certainly consider sending the patient to a mental health practitioner. There are support groups available for people suffering from chronic pain. The lead author has seen many patients who were told by other healthcare professionals that they are “crazy” or that they should just live with the pain, and this is very devastating to them. Fortunately, once the proper diagnosis of a peripheral nerve problem was made, they no longer felt “crazy” and realized they had a physical problem and their depression improved.

   Another consideration is to check the hormone levels of your patients. Often, people who have been suffering with chronic pain from neuropathy will have elevated hormones and this sets off a whole cascade of events that are involved in the neurochemistry of pain. The adrenocorticotropic hormone likely plays a critical role here.

Is There Merit To ‘Super Vitamins’?

Recently, “super vitamins” or nerve nutrient formulation via oral routes have been in widespread use. Specifically, these super vitamins nourish the nerves affected by peripheral neuropathy and allow them to conduct impulses more normally, decreasing symptoms. Almost all of these formulations contain benfotiamine. These formulations are in use worldwide and have had mixed results in easing the symptoms of pain, burning, numbness and tingling in patients with peripheral neuropathy.18,19

   Benfotiamine has been in use since the early 1960s and has successfully helped tens of thousands of patients suffering from peripheral neuropathy worldwide. It has received widespread study in the scientific literature along with vitamin B derivatives and research has shown that benfotiamine has efficacy in a significant number of patients.18,19

Does Laser Therapy Have Promise For Neuropathy?

Cold laser therapy has been around for quite awhile and we are sure many of you reading this have seen demonstrations of these lasers at meetings or even in your office. Most of the data and research of cold laser therapy has occurred in Asia. We have only recently been exposed to its potential benefits and we may only be at the tip of the iceberg regarding the potential benefit to patients.

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