Feature Article

Painful neuropathy in diabetes: recognising and relieving




The painful form of diabetic peripheral neuropathy can be severely disabling but is often underappreciated and undertreated. It can occur in the absence of sensory loss and may follow improved glycaemic control or even be the presenting symptom of diabetes. Treatment is symptomatic, aiming to reduce pain and improve function.

Key Points

  • Painful diabetic peripheral neuropathy can be severely disabling and adversely impact on patient quality of life.
  • The diagnosis of painful diabetic peripheral neuropathy is predominantly clinical; it relies on careful history taking and physical examination to exclude alternative causes of pain, and often routine blood tests to help exclude other causes of painful neuropathy.
  • In some atypical presentations, nerve conduction studies and electromyography can be helpful to exclude other types of neuropathy.
  • No medications are known to affect the natural history of painful diabetic peripheral neuropathy; medications used are symptomatic treatments only.
  • Common first-line medications to control the pain of diabetic neuropathy include the anticonvulsants pregabalin and gabapentin, amitriptyline and duloxetine; opioid analgesia is an evidence-based option for second-line therapy but requires judicious prescribing.
  • Patients with pain that is more difficult to manage may benefit most from specialist care, including in a multidisciplinary setting.

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