Key Insights On Using Medications In Wound Care
For example, Dr. Rogers says the dosing for gabapentin in the Physicians Desk Reference is 100 to 300 mg/day but he cautions that this dosing is for the drug’s approved epilepsy indication, not painful neuropathy. Research has shown that one must prescribe gabapentin in excess of 1,800 mg/day (divided TID) in order for the medication to be effective for neuropathic pain, according to Dr. Rogers.1 Dr. Suzuki has found gabapentin frustrating given its gradual upward tapering and pain relief that can be hit or miss.
Dr. Suzuki formerly prescribed tricyclic antidepressants for neuropathy but says the side effects can be harsh and intolerable for many patients. When it comes to painful diabetic neuropathy, Dr. Satterfield notes she has had less than 30 percent of patients achieving pain relief with amitriptyline. When she has combined this with acetaminophen, patients had 60 percent achieving pain relief at night. Dr. Satterfield notes that some physicians add diphenhydramine (Benadryl) to help patients with DPN get through the night.
Although advances in medicine have gone beyond this “neuropathy pain cocktail” combination, Dr. Satterfield says this can still be “a good option” for patients who do not have good insurance and cannot afford the newer generation drugs.
Dr. Satterfield reminds DPMs of the transient nature of diabetic neuropathy. She notes that it can be painful at times and patients can have no sensation from this at other times.
“It is those painful episodes we have to treat,” maintains Dr. Satterfield.
Q: Do you have a supplement of choice for neuropathic pain?
A: Dr. Suzuki has found some success treating neuropathic pain adjunctively with Metanx (Pamlab), a supplement comprised of folic acid and vitamin B complex, which reverses the endothelial dysfunction and increases the nitric oxide release. He cites a recent study indicating increased cancer incidence and mortality after treatment with folic acid and vitamin B12.2 Although the study may not be completely applicable with Metanx, Dr. Suzuki says it is something to consider.
Dr. Suzuki notes clinical evidence that some antioxidant supplements, such as alpha lipoic acid, may slow down the progression of diabetic neuropathy. The SYDNEY 2 trial showed that 600 mg of alpha-lipoic acid once a day PO improved neuropathic symptoms and deficits in patients with diabetic neuropathy as early as four weeks of treatment.3 The NATHAN 1 trial also showed that alpha-lipoic acid was well-tolerated and improves some neuropathic deficits and symptoms in mild to moderate neuropathy.4
Dr. Satterfield has used “the whole gamut of supplements” for painful diabetic neuropathy. While she believes some supplements have a positive effect, she calls for more randomized, controlled studies to prove their efficacy. To date, Dr. Rogers says no randomized, controlled trial has shown dietary supplements to be effective for neuropathic pain.
“I refuse to use a dietary supplement for neuropathic pain and consider it cruel if it were the sole treatment,” says Dr. Rogers.
Furthermore, Dr. Rogers notes the etiology of diabetic neuropathy is not a vitamin deficiency but likely a hypoxic nerve injury from microvascular damage. He compares diabetic neuropathic pain to the pain of the foot falling asleep and waking up.
“Now imagine that the only treatment your doctor offered you for this pain was a vitamin. How satisfied would you be with this treatment?” he asks. “There is also a lack of sound evidence to use supplements for non-painful sensory neuropathy but it probably does no harm to use them adjunctively.”
Dr. Rogers is an Associate Medical Director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine.
Dr. Satterfield is an Adjunct Associate Professor at the Western University College of Podiatric Medicine. She is a Fellow and President-Elect of the American College of Foot and Ankle Orthopedics and Medicine.