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Issue link: https://eguideline.guidelinecentral.com/i/1499275
Key Points ➤ Clinicians should offer tricyclic antidepressants (TCAs), serotonin- norepinephrine reuptake inhibitors (SNRIs), gabapentinoids, and/or sodium channel blockers to reduce pain. ➤ Clinicians should not use opioids for the treatment of painful diabetic neuropathy. ➤ For patients with painful diabetic neuropathy, clinicians should review all of the available options to reduce pain, including oral, topical, and nonpharmacologic interventions. ➤ It is important for clinicians to think about treatment of painful diabetic neuropathy in terms of medication class. Patients need to be re- evaluated, in regard to efficacy and tolerability, after starting treatment. If a medication in one class is not working or is causing intolerable side effects, another medication class should be tried instead of another medication in the same class. Key Points Treatment Initial Assessment ➤ Clinicians should assess patients with diabetes for peripheral neuropathic pain and its effect on these patients' function and quality of life (Level B). ➤ When initiating pharmacologic intervention for painful diabetic neuropathy, clinicians should counsel patients that the goal of therapy is to reduce, and not necessarily to eliminate, pain (Level B). ➤ Clinicians should assess patients with painful diabetic neuropathy for the presence of concurrent mood and sleep disorders and treat them as appropriate (Level B). ➤ In patients with painful diabetic neuropathy, clinicians should offer gabapentinoids, TCAs, SNRIs, and/or sodium channel blockers to reduce pain (Level B). ➤ Clinicians may assess patient preferences for effective oral, topical, nontraditional, and nonpharmacologic interventions for painful diabetic neuropathy (Level C). ➤ In patients preferring topical, nontraditional, or nonpharmacologic interventions, providers may offer topicals (capsaicin, glyceryl trinitrate spray, Citrullus colocynthis), nontraditional (ginkgo biloba), and/or nonpharmacologic interventions (cognitive behavioral therapy [CBT], exercise, Tai Chi, mindfulness) (Level C).