Information
Painful peripheral neuropathy affects up to 10% of people with diabetes. Around half seek treatment. Characteristic features are burning, tingling and electric shocks in both feet, worse at night or on resting.
There is no correlation with degree of sensory loss.
Unilateral symptoms or pain on walking are not typical features, consider musculoskeletal sources or vascular disease.
Who can refer:
Any primary care clinician who has followed the primary care guidance and the patient still has significant symptoms
Who to refer:
Patients who have not responded to first line therapies
Who not to refer:
People with mechanical, referred or dysvascular pain. People without diabetes.
How to refer:
SCI Gateway, (patient will be seen by the consultant on the MDT clinic days at RIE only) or if all the possible first line therapies have been exhausted at the maximum tolerated dose, consider direct referral to a specialist pain clinic
All treatments are individually only around 50% successful in alleviating pain.
First line treatment would be to improve diabetes control, especially variability in glucose levels. Exclude other causes such as alcohol excess, vitamin B12 deficiency (especially in metformin treated patients) and other neurological conditions.
If prescribing drug therapies:
- Try simple analgesia such as Paracetamol. Tramadol can be used for acute breakthrough pain relief in the short term.
- For sleep disturbance caused by PPN try Amitriptyline 10mg increased to a maximum of 100mg
- If low in mood, try Duloxetine 30mg increased to a maximum of 120mg
- If neither, then try gabapentinoids – either Gabapentin (note need to titrate to over 1800mg before deciding ineffective) or Pregabalin (has fewer dose steps) up to 300mg twice daily (adjust both for CKD).
Review patients regularly and titrate one medication to the maximum tolerated dose before considering a switch
NICE Guideline – Neuropathic pain in adults: pharmacological management in non-specialist settings
