Painful Diabetic Peripheral Neuropathy (PDN) is common, affecting around a quarter
of patients with both type 1 and type 2 diabetes, and can lead to significant curtailment
of functionality and quality of life. Patients may present with unremitting burning,
aching or "electric-shock" type pains in their feet, legs and later, in the hands.
Conventional management approaches must focus not only on pain relief, but also on
concurrent sleep problems, mood disorders and functionality. The mainstay of treatment
is pharmacotherapy. Most current international guidelines recommend a choice of four
drugs: amitriptyline, duloxetine, pregabalin or gabapentin, as initial treatment for
PDN. Recent evidence from the OPTION-DM trial demonstrated that these drugs and their
combinations have equivalent efficacy. Moreover, combination treatment provided significant
pain relief to patients with inadequate response to the maximum tolerated dose of
monotherapy. PDN refractory to pharmacotherapy can be treated with capsaicin 8% or
high frequency spinal cord stimulation.
