Painful diabetic
peripheral neuropathy (
DPN) is common, is associated with significant reduction in quality of life and poses major treatment challenges to the practising physician. Although poor
glucose control and cardiovascular risk factors have been proven to contribute to the aetiology of
DPN, risk factors specific for painful
DPN remain unknown. A number of instruments have been tested to assess the character, intensity and impact of painful
DPN on quality of life,
activities of daily living and mood. Management of the patient with
DPN must be tailored to individual requirements, taking into consideration the co-morbidities and other factors. Pharmacological agents with proven efficacy for painful
DPN include tricyclic anti-depressants, the selective
serotonin and
noradrenaline re-uptake inhibitors, anti-
convulsants,
opiates, membrane stabilizers, the
anti-oxidant alpha-lipoic acid and topical agents including
capsaicin. Current first-line
therapies for painful
DPN include tricyclic anti-depressants, the
serotonin and
noradrenaline re-uptake inhibitor
duloxetine and the anti-
convulsants pregabalin and
gabapentin. When prescribing any of these agents, other co-morbidities and costs must be taken into account. Second-line approaches include the use of
opiates such as synthetic
opioid tramadol,
morphine and
oxycodone-controlled release. There is a limited literature with regard to combination treatment. In extreme cases of painful
DPN unresponsive to
pharmacotherapy, occasional use of electrical
spinal cord stimulation might be indicated. There are a number of unmet needs in the therapeutic management of painful
DPN. These include the need for randomized controlled trials with active comparators and data on the long-term efficacy of agents used, as most trials have lasted for less than 6 months. Finally, there is a need for appropriately designed studies to investigate non-pharmacological approaches.