February 2022

Guideline Update: AAN Updates Guideline for Oral/Topical Treatment of Painful Diabetic Neuropathy

The American Academy of Neurology (AAN) has updated its guideline on oral and topical treatments for painful diabetic neuropathy (PDN). The revised guideline,1 which was published in the journal Neurology and updates the 2011 AAN guideline, has been endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine.

“Living with pain can greatly affect a person’s quality of life, so this guideline aims to help neurologists and other doctors provide the highest quality patient care based on the latest evidence,” said guideline author Brian C. Callaghan, MD, MS, of the University of Michigan in Ann Arbor and a Fellow of the AAN, in a press release. “Painful diabetic neuropathy is very common, so people with diabetes who have nerve pain should discuss it with their doctor because treatment may help.”

While several oral and topical medications are effective in reducing nerve pain, the guideline encourages clinicians—before prescribing—to first determine if a patient also has mood or sleep problems as treatment for these conditions is also important. To reduce nerve pain, the guideline recommends that clinicians offer treatments from the following drug classes: tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline, and imipramine; serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, venlafaxine, or desvenlafaxine; gabapentinoids such as gabapentin or pregabalin; and/or sodium channel blockers such as carbamazepine, oxcarbazepine, lamotrigine, or lacosamide.

Evidence shows all of these medications may reduce nerve pain. “New studies on sodium channel blockers published since the last guideline have resulted in these drugs now being recommended and considered as effective at providing pain relief as the other drug classes recommended in this guideline,” said Callaghan. When prescribing, the guideline says clinicians should consider the cost of a drug and side effects, as well as other medical problems the person may have. Once taking a drug, patients should be checked regularly by their clinicians to determine if there is enough pain relief or too many side effects. If the first medication tried does not provide meaningful improvement, or if there are significant side effects, the guideline states that clinicians should offer patients a trial of another medication from a different class.

The guideline recommends against starting opioids, including tramadol and tapentadol, for PDN, and recommends offering the option of a safe taper off opioids for those already taking them. “Current evidence suggests that the risks of the use of opioids for painful diabetic neuropathy therapy outweigh the benefits, so they should not be prescribed,” said Callaghan. The guideline states that clinicians may offer topical treatments such as capsaicin, glyceryl trinitrate spray, or Citrullus colocynthis to reduce pain. It also says ginkgo biloba may be helpful, as well as non-drug treatments such as exercise, mindfulness, cognitive behavioral therapy, or tai chi.

“It is important to note that the recommended drugs and topical treatments in this guideline may not eliminate pain, but they have been shown to reduce pain,” said Callaghan. “The good news is there are many treatment options for painful diabetic neuropathy, so a treatment plan can be tailored specifically to each person living with this condition.”

To further assist clinicians treating patients with polyneuropathy, the AAN has also developed a new AAN Polyneuropathy Quality Measurement Set2 to accompany this guideline, published as a special article in the journal Neurology. A quality measurement set is a tool healthcare providers can use to improve the ways care is delivered to patients. According to the guideline, a key driver was the lack of clinician-patient interaction regarding pain—rarely is it discussed, and even when it is, patients are often not treated. Indeed, the authors cite evidence that shows 12.5% of patients with diabetes and chronic painful peripheral neuropathy do not report symptoms to their clinicians and nearly 40% receive no treatment for this condition.

The set includes 3 quality measures:

Avoidance of opioid medications for patients with diabetic neuropathy: This measure is designed to limit the number of new and existing opioid prescriptions for this patient population.

Pain assessment and appropriate treatment for patients with diabetic neuropathy: This is a paired measure designed to assess the percentage of patients with whom pain was discussed AND had an appropriate medication offered. The quality measures encourage assessment of pain in all patients with polyneuropathy, especially African American and Hispanic patients as a means of reducing already identified health disparities, particularly in provider-patient communications.

Reduction of pain for patients with polyneuropathy: This outcome measure applies to patients diagnosed with polyneuropathy—not just DPN—whose pain scores are reduced by 30% over a 12-month period.

The American Academy of Neurology Institute worked with the Logical Observation Identifiers Names and Codes (LOINC) to facilitate code capture from electronic medical records to make implementation of these measures easier for clinicians. To learn more, both publications are available via open access (details below).

REFERENCES
  1. Price R, Smith D, Franklin G, et al. Oral and topical treatment of painful diabetic polyneuropathy: Practice guideline update summary. Neurology. 2022;98;31-43.
  2. Callaghan BC, Armon C, Bril V, et al. Polyneuropathy quality measurement set: quality improvement in neurology. Neurology. 2022;98;22-30.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.