Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee

Raymond Price; Don Smith; Gary Franklin; Gary Gronseth; Michael Pignone; William S David; Carmel Armon; Bruce A Perkins; Vera Bril; Alexander Rae-Grant; John Halperin; Nicole Licking; Mary Dolan O'Brien; Scott R Wessels; Leslie C MacGregor; Kenneth Fink; Lawrence B Harkless; Lindsay Colbert; Brian C Callaghan

doi:10.1212/WNL.0000000000013038

Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee

Neurology. 2022 Jan 4;98(1):31-43. doi: 10.1212/WNL.0000000000013038.

Authors

Raymond Price¹, Don Smith¹, Gary Franklin¹, Gary Gronseth¹, Michael Pignone¹, William S David¹, Carmel Armon¹, Bruce A Perkins¹, Vera Bril¹, Alexander Rae-Grant¹, John Halperin¹, Nicole Licking¹, Mary Dolan O'Brien¹, Scott R Wessels², Leslie C MacGregor¹, Kenneth Fink¹, Lawrence B Harkless¹, Lindsay Colbert¹, Brian C Callaghan¹

Affiliations

¹ From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor.
² From the Department of Neurology (R.P.), University of Pennsylvania, Philadelphia; Department of Neurology (D.S.), University of Colorado, Aurora; Department of Neurology (G.F.), University of Washington, Seattle; Department of Neurology (G.G.), University of Kansas Medical Center, Kansas City; Department of Internal Medicine (M.P.), The University of Texas at Austin Dell Medical School; Department of Neurology (W.S.D.), Massachusetts General Hospital, Boston; Department of Neurology (C.A.), Tel Aviv University Sackler School of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel; Leadership Sinai Centre for Diabetes (B.A.P.), Sinai Health System, University of Toronto; Division of Neurology (V.B.), Department of Medicine, Toronto General Hospital, Canada; Professor Emeritus (A.R.-G.), Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH; Department of Neurosciences (J.H.), Overlook Medical Center, Summit, NJ; New West Physicians (N.L.), Golden, CO; American Academy of Neurology (M.D.O., S.R.W.), Minneapolis, MN; Neuropathy Action Foundation (L.C.M.), Santa Ana, CA; Kamehameha Schools (K.F.), Honolulu, HI; University of Texas Rio Grande Valley School of Podiatric Medicine (L.B.H.), Edinburg; The Foundation for Peripheral Neuropathy (L.C.), Buffalo Grove, IL; and Department of Neurology (B.C.C.), University of Michigan, Ann Arbor. guidelines@aan.com.

PMID: 34965987
DOI: 10.1212/WNL.0000000000013038

Abstract

Objective: To update the 2011 American Academy of Neurology (AAN) guideline on the treatment of painful diabetic neuropathy (PDN) with a focus on topical and oral medications and medical class effects.

Methods: The authors systematically searched the literature from January 2008 to April 2020 using a structured review process to classify the evidence and develop practice recommendations using the AAN 2017 Clinical Practice Guideline Process Manual.

Results: Gabapentinoids (standardized mean difference [SMD] 0.44; 95% confidence interval [CI], 0.21-0.67), serotonin-norepinephrine reuptake inhibitors (SNRIs) (SMD 0.47; 95% CI, 0.34-0.60), sodium channel blockers (SMD 0.56; 95% CI, 0.25-0.87), and SNRI/opioid dual mechanism agents (SMD 0.62; 95% CI, 0.38-0.86) all have comparable effect sizes just above or just below our cutoff for a medium effect size (SMD 0.5). Tricyclic antidepressants (TCAs) (SMD 0.95; 95% CI, 0.15-1.8) have a large effect size, but this result is tempered by a low confidence in the estimate.

Recommendations summary: Clinicians should assess patients with diabetes for PDN (Level B) and those with PDN for concurrent mood and sleep disorders (Level B). In patients with PDN, clinicians should offer TCAs, SNRIs, gabapentinoids, and/or sodium channel blockers to reduce pain (Level B) and consider factors other than efficacy (Level B). Clinicians should offer patients a trial of medication from a different effective class when they do not achieve meaningful improvement or experience significant adverse effects with the initial therapeutic class (Level B) and not use opioids for the treatment of PDN (Level B).

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Antidepressive Agents, Tricyclic
Diabetes Mellitus* / drug therapy
Diabetic Neuropathies* / drug therapy
Humans
Neurology*
Pain / drug therapy
Selective Serotonin Reuptake Inhibitors / therapeutic use
United States

Substances

Antidepressive Agents, Tricyclic
Serotonin Uptake Inhibitors