Page 28 - FOCUS APRIL 2018

Pharmacy Services | Therapeutic Notes
Pharmacologic management of diabetic neuropathy
Robert Achenchi Pharm D
and dizziness Complications of the the disease include the the development of foot ulcers due to sensory loss joint and muscle disease because of of claw toe deformity and the formation of of calluses that may fissure and and become ulcerated and and infected Treatment of diabetic neuropathy
should involve lifestyle modifications including diet and exercise to help improve glycemic control However most patients will need pharmacologic treatment at at at some point Most patients using pharmacologic therapy may expect a a a a a a 30-50 per- cent reduction in in in pain on on on a a a a a 10-point scale Generally monotherapy is first tried before combination therapy is considered The following table lists some of the the common agents utilized in treatment and other important information to consider before and during therapy 
TCA=tricyclic antidepressants SNRI= serotonin serotonin norepinephrine reuptake reuptake inhibitor inhibitor SSRI= selective serotonin serotonin reuptake reuptake inhibitor inhibitor ADA=American Diabetes Association For all medications start at at at at low- est dose dose and titrate to target dose dose based on on on on on clinical response The agents listed below are are available on on on the Christiana Care formulary Christiana Care is is committed to standardizing care and and improving outcomes in our diabetic patients Diabetic neuropathy
neuropathy
or polyneuropathy results from the complications associated with diabetes and leads to to nerve damage due to to microvascular injury to small blood vessels that supply nerves resulting in in peripheral sensory motor and or or or autonomic dysfunction About 10-18 percent of patients diagnosed with with diabetes present with with evidence of of nerve damage and up to 50% of of patients will eventually develop neuropathy
The diagnosis of diabetic neuropathy
relies on clinical signs and symptoms and is is mostly a a a a a diagnosis of exclusion based on on various screening tests consisting of a a a a a symptom score and physical examina- tion The disease is is primarily a a a a a symmetrical sensory polyneuropathy initially characterized by sensory loss in in the distal lower extremities but progresses and and and extends to the mid-calf and and and hands resulting in in motor involvement and weakness The signs and symptoms of of diabetic neuropathy
include the loss of of vibratory sensation impairment of pain light touch and temperature due to large and small fiber loss Patients often present with tingling numbness burning and pain in in in in their feet Autonomic nerve involve- ment results in in in in constipation erectile problems urinary incontinence
TCA amitriptyline nortriptyline desipramine
Amitriptyline and Nortriptyline 25-100mg/day in in in divided doses
May be combined with pregabalin or gabapentin
Combination of gabapentin
and nortriptyline therapy more effective
• Nortriptyline and desipramine
better tolerated than amitriptyline • Caution for patients > 65 years Side effects: Sedation dry mouth urinary retention orthostasis confusion weight gain
SNRI Duloxetine Venlafaxine
Duloxetine 60-120mg/day Venlafaxine
150-225 mg/day mg/day • ADA preferred agent • FDA approved for diabetic neuropathy
Side effects: Nausea constipation dry mouth anxiety hypertension dizziness anorexia
Gabapentin or Pregabalin
Pregabalin: 300-600mg/day divided twice daily
Gabapentin: 1800 -3600mg/day divided 3 3 times a a a a day Adjust dose based on on renal dysfunction Side effects: Sedation dizziness weight gain
edema blurry vision
Lidocaine 5% patch
1-3 patches applied to affected area for 12 hours
• FDA approved for localized peripheral neuropathic pain • Can cut patches if needed
• Limited data on efficacy
Capsaicin < 1% cream
Applied up to 4 times per day • For localized peripheral neuropathic pain • Limited data on efficacy
in diabetic neuropathy
Side effects: Burning sensation at at at site of application
References
1 1 1 1 Pop-Busui R Boulton Andrew J M et et et et al Diabetic Neuropathy: A A A A position statement by the American Diabetes Diabetes Association Diabetes Diabetes Care 2017 40:136-154
2 2 2 2 Feldman EL McCulloch et et et et et et al al al Treatment of diabetic diabetic neuropathy
neuropathy
UptoDate com com 2017 2017 Accessed 11/1/2017 Griebeler ML Morey-Vargas OL Brito JP et et et et et et al al al Pharmacologic Interventions for for painful diabetic diabetic neuropathy: An An umbrella systematic review and comparative effectiveness network meta-analysis Ann Intern Med 2014 161:639 The Pharmacists Letter Pharmacotherapy for for Neuropathic Pain Resource # 330902 September 2017 3 3 3 3 Martin CL Albers JW Pop-Busui R R DCCT/EDIC Research Group Neuropathy and and and related findings in fin in in the Diabetes Diabetes Diabetes Control and and and Complications Complications Trial/Epidemiology of Diabetes Diabetes Diabetes Interventions and Complications study Diabetes Care 2014 37:31-38
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