Painful Diabetic Neuropathy ‐ A Therapeutic Challenge For The New Millennium

Abstract

Although less than 20% of patients with diabetic neuropathy experience severe symptoms, the management of painful diabetic neuropathy presents a major therapeutic challenge. Pain may occur as a feature not only of chronic or acute sensory neuropathy, but also the focal neuropathies, however, this lecture will focus on pain in symmetrical distal polyneuropathy. A number of theories exist to explain the mechanisms of pain in diabetic neuropathy: these include ectopic impulse formation by regenerating sprouting axons, various neuro structural theories and, more recently, ischaemia of peripheral nerve due to active epineurial arterio venous shunting. A number of scoring systems exist to assess neuropathic pain: which ever is used, it must rely upon the patient's description of the painful symptoms they are experiencing. A therapeutic approach to neuropathic pain should firstly exclude non‐diabetic causes of neuropathy, and then aim to obtain optimal stable glycaemic control. A number of therapeutic agents exist that have been shown in controlled trials to alleviate painful neuropathic symptoms; these include the tricyclic drugs, newer anti convulsant agents such as Gabapentin and Topiramate, and also the centrally‐acting drug Tramadol. Some evidence exists for the efficacy of the topical agent Capsaicin. Other promising new agents include alpha lipoic acid. A number of therapies may well be helpful although unproven in controlled trials, and these include acupuncture and electrical spinal cord stimulation.