What is the best treatment for peripheral neuropathy?

Over-the-counter pain relievers, such as non-steroidal anti-inflammatory drugs, may relieve mild symptoms. Care at Mayo Clinic · Physicians and Departments · Anti-seizure medications. For more severe symptoms, your doctor may prescribe pain medication. Surgical treatment may be recommended for people with nerve damage due to nerve injury or compression.

Mobility aids, such as a cane, walker, or wheelchair, may be helpful. For pain, the doctor may prescribe painkillers. You can relieve neuropathic pain by using apple cider vinegar. Apple cider vinegar is one of the best folk remedies used for the treatment of neuropathy.

This is a corrected version of the article that appeared in print. GIBBS, MD, Family Medicine Residency at Saint Louis University, Belleville, Illinois TAMMY J. LINDSAY, MD, Family Medicine Residency at Saint Louis University,. Louis, Missouri This clinical content meets the AAFP criteria for continuing medical education (CME).

Painful diabetic peripheral neuropathy occurs in approximately 25% of patients with diabetes mellitus who receive treatment in the office and significantly affects quality of life. It usually causes burning pain, paresthesias, and numbness in an average glove pattern that progresses proximally from the feet and hands. Physicians should carefully consider the patient's goals and functional status and possible adverse effects of medication when choosing a treatment for painful diabetic peripheral neuropathy. Pregabalin and duloxetine are the only drugs approved by the U.S.

UU. Food and Drug Administration (FDA) to treat this disorder. According to current practice guidelines, these drugs, along with gabapentin and amitriptyline, should be considered for initial treatment. Second-line therapy includes opioid-like medications (tramadol and tapentadol), venlafaxine, desvenlafaxine, and topical agents (lidocaine patches and capsaicin cream).

Isosorbide dinitrate aerosol and transcutaneous electrical nerve stimulation may provide relief in some patients and may be considered at any time during treatment. Opioids and selective serotonin reuptake inhibitors are optional third line drugs. Acupuncture, traditional Chinese medicine, alpha lipoic acid, acetyl-l-carnitine, evening primrose oil and the application of the electromagnetic field lack high-quality evidence to support their use. Painful diabetic peripheral neuropathy (PND) occurs in approximately 30% of patients with diabetes mellitus who are hospitalized and in 25% of patients with diabetes who are treated in the office, 1 It develops as a late manifestation of uncontrolled or long-term diabetes, 1 Up to 12% of patients with Painful PND report no symptoms, and 39% of patients with the disorder do not receive any treatment, 2 Pregabalin (Lyrica), gabapentin (Neurontin), amitriptyline (except in older adults) or duloxetine (Cymbalta) should be used as first-line treatment for painful diabetic peripheral neuropathy.

5% lidocaine patch, 0.075% capsaicin cream, isosorbide dinitrate spray and transcutaneous electrical nerve stimulation can be added to therapy for painful diabetic peripheral neuropathy. Distal symmetrical polyneuropathy, which is characterized by burning pain, paresthesias and numbness that follows an average glove pattern and progresses proximally, occurs in approximately 26% of patients with PND. Less than 20% of patients with diabetes experience dynamic mechanical allodynia (pain in response to mild stroking), thermal hyperalgesia (increased sensitivity to pain due to thermal stimuli) or pain attacks. Pharmacological and non-pharmacological interventions are available for the treatment of painful PND.

However, there are few direct, high-quality clinical trials comparing these therapeutic approaches, and because available studies use variable methodologies, it is difficult to know which treatment strategy may be most effective. Only two drugs, pregabalin (Lyrica) and duloxetine (Cymbalta), have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of DPN. However, guidelines from national organizations such as the American Academy of Neurology recommend the use of a wider range of medications.

Figure 1 presents a treatment algorithm for painful PND based on available evidence, 1—3,5—8 Selected drugs and their doses, costs and numbers needed to treat (NNT) are presented in Table 1, 1, 7, 9—14 Table 2 lists the common adverse effects of drugs used to treat painful PND, 3,12,13 1.15 interactions are described in Table 3.16 NNT %3D 1 to 3, NNH %3D 28 (major adverse events), 6 (minor adverse effects) ‡ Serotonin-norepinephrine reuptake inhibitors Selective serotonin reuptake inhibitors ER %3D prolonged release; NA %3D not available; NNH %3D number needed to damage; NNT %3D number needed to treat. No side effects significantly different from placebo May increase the toxic effects of CNS depressants, * SSRIs, thiazolidinediones Toxic effects may be increased by CNS depressants, * ACCH inhibitors, hydroxyzine and magnesium sulfate May increase the toxic effects of CNS depressants, * QTC prolongants† SSRI, St. John's wort, sulphonylureas, tramadol and warfarin (Coumadin) Efficacy may be reduced with St. John's wort, ACCH inhibitors and carbamazepine (Tegretol) Absolutely contraindicated with MAO inhibitors May increase the toxic effects of CNS depressants, * antiplatelet agents, alpha and beta agonists, anticoagulants (e.g.

Pregabalin provides consistent pain relief based on a dose-dependent response compared to placebo. A meta-analysis of seven RCTs (#3D 1.59) comparing pregabalin with placebo showed that doses of 300 mg daily and 600 mg daily (or divided twice daily) resulted in greater than 50% reduction in pain in 39 and 47% of patients, respectively, vs. The onset of action occurred at five days with 300 mg and after four days with 600 mg. The 150 mg daily dose was ineffective, 1-3 gabapentin in doses of 1200 mg daily or more is more effective than placebo and has been shown to have a similar effect to that of pregabalin (reduction of symptoms from 8 to 13%) based on nine RCTs (n% 3D 1.60.

Compared to amitriptyline, similar efficacy was observed in at least five RCTs. Few high-quality studies have investigated the effectiveness of valproate, topiramate, carbamazepine (Tegretol), oxcarbazepine, lamotrigine, and lacosamide. Therefore, these agents are not recommended for the treatment of painful PND, 2,17 isosorbide dinitrate spray, 5% lidocaine patch or plaster and 0.075% capsaicin cream should also be considered for the treatment of painful DPN, 2 Isosorbide dinitrate is a vasodilator and smooth muscle relaxant that produced an 18% reduction in pain score when sprayed on the skin of areas affected by painful PND in a small RCT of 22 patients, 2,27 Can be introduced at any time as an adjunctive treatment. Treatment with 5% lidocaine patch or medicated plaster produced pain relief comparable (30-50% response) to that of pregabalin (66.7% vs.

There was a greater improvement in quality of life scores and fewer adverse effects in the lidocaine group than in the pregabalin group, 28 Other concentration levels and combined treatments have also been studied. In particular, the combination of 0.025% capsaicin with 3.3% doxepin led to a decrease in skin irritation compared to capsaicin alone (an ACE, No. 3D 200, 61% vs. Combined data from four small studies reveal an NNT of 7 for pain reduction with this class of drugs, 30 Despite concerns about dependency and lower-quality evidence about the benefit of chronic opioid therapy for non-malignant pain12, the guidelines suggest a potential benefit for the patients with painful PND, 2,5,31 However, opioid monotherapy is not a first-line treatment and should be reserved for patients who do not achieve the goals of pain relief and functional improvement with other therapies, 2.5 Notably, most studies on the use of opioids for neuropathic pain are short-term studies term, 14 tolerance and hyperalgesia, 32 Acupuncture, which has been the focus of 75 low-quality RCTs; traditional Chinese medicine, which generally includes acupuncture and herbal medicine; and the application of electromagnetic fields are not currently recommended for the treatment of painful PND because large and high-quality RCTs are missing, 2, 34—36 The results of several small studies suggest that transcutaneous electrical nerve stimulation (TENS) should be considered as a treatment for painful PND, 40 An RCT involving 31 participants showed that 15 out of 18 (83%) patients who received TENS had better pain scores (reduction from 3.17 to 1.44 in a 5-point scale) versus.

Five out of 13 (38%) patients receiving sham treatments (reduction from 2.98 to 2.3). The opinions and statements contained in this document are the private opinions of the authors and should not be interpreted as official or reflecting the views of the University of Saint Louis, USA. Air Force Medical Service, or U.S. This review updates an earlier article on this topic by Lindsay, Rodgers, Savath and Hettinger, 43 Already a member or subscriber? Login Are you interested in becoming a member of the AAFP? More about MATTHEW J.

SNYDER, DO, FAAFP, is associate director of the Family Medicine Residency Program at Saint Louis University in Belleville, Illinois. GIBBS, MD, FAAFP, is an adjunct clinical professor in the Family Medicine Residency Program at Saint Louis University, Belleville. LINDSAY, MD, FAAFP, is an associate clinical professor in the Department of Family and Community Medicine at Saint Louis University School of Medicine, St. Louis University, St.

Access the latest edition of American Family Physician. Some over-the-counter medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs), can relieve mild pain and discomfort. In addition, topical medications, such as lidocaine patches or creams, may be effective if the pain is limited to a small area. Capsaicin cream derived from a substance found in hot peppers can relieve neuropathic pain and itching.

In more severe cases, the doctor may prescribe narcotic drugs. These can be habit-forming, so it is very important to use these potent drugs only as prescribed. Some antidepressants and anti-seizure medications may also be helpful in treating symptoms of nerve pain. Ask your doctor if you are an ideal candidate for these drugs.

Finally, some doctors may also prescribe medication to treat the underlying condition that is causing neuropathy. This tactic may include using medicines to resolve infections or mitigate the effects of diabetes, high blood pressure, or autoimmune conditions. Tobacco products and excessive alcohol use can also play a role in nerve damage. While quitting smoking isn't easy, there are numerous programs and medications to help manage withdrawal symptoms.

Ideally, limit alcohol consumption to 1-2 drinks a day at most. Your doctor may choose one of several treatments if peripheral neuropathy is the result of autoimmune problems. Treatments may include oral medications or intravenous infusion treatments. For example, azathioprine and prednisone are common medications that your doctor may prescribe.

Acupuncture usually has few or no side effects. In fact, it can be done despite certain medications that the patient is taking. Be sure to check with your doctor to find out if you would be an ideal candidate for acupuncture. Treatment of peripheral neuropathy depends on the cause.

Some common treatments include physical therapy, surgery, and injections to increase nerve pressure. Other treatments focus on reducing pain and discomfort with over-the-counter pain relievers such as ibuprofen or aspirin. Neuropathy is the general term used to describe nerve damage, while peripheral neuropathy is a type of neuropathy that involves damage to the peripheral nerves. Early diagnosis and treatment of peripheral neuropathy is important, because peripheral nerves have a limited ability to regenerate and treatment can only stop progression, not reverse damage.

A neurologist, or a doctor who specializes in treating disorders of the central and peripheral nervous system, is the best doctor to treat neuropathies. Pregabalin (Lyrica), gabapentin (Neurontin), amitriptyline (except in older adults) or duloxetine (Cymbalta) should be used as a first-line treatment for painful diabetic peripheral neuropathy. Treatment depends on the underlying cause of the disorder, but in most cases peripheral neuropathy cannot be cured. The effective prognosis and treatment of peripheral neuropathy largely depends on the cause of nerve damage.

The primary goal of treating peripheral neuropathy is to address the underlying cause of the condition while at the same time providing relief from symptoms. The Department of Neurosurgery at Rutgers Health and RWJBarnanbas Health uses a multidisciplinary approach to the treatment of peripheral neuropathy. Patients with peripheral neuropathy should always inform their neurologist or medical team about any holistic medicine techniques they are using to help treat their symptoms of peripheral neuropathy. .


Jeffery Loria
Jeffery Loria

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