AAN GUIDELINES Bundle

Treatment ➤ Given similar efficacy, clinicians should consider factors other than efficacy, including potential adverse effects, patient comorbidities, cost, and patient preferences, when recommending treatment for painful diabetic neuropathy (Level B). ➤ In patients of child-bearing potential with painful diabetic neuropathy, clinicians should not offer valproic acid (Level B). ➤ In all patients with painful diabetic neuropathy, clinicians should not prescribe valproic acid given the potential for serious adverse events unless multiple other effective medications have failed (Level B). ➤ Clinicians should counsel patients that a series of medications may need to be tried to identify the treatment that most benefits patients with painful diabetic neuropathy (Level B). ➤ Clinicians should determine that an individual intervention to reduce neuropathic pain is a failure either when the medication has been titrated to a demonstrated efficacious dose for approximately 12 weeks without clinically significant pain reduction or when side effects from the medication outweigh any benefit in reduced neuropathic pain (Level B). Medication ➤ Clinicians should offer patients a trial of a medication from a different effective class when they do not achieve meaningful improvement or if they experience significant adverse effects with the initial therapeutic class (Level B). ➤ For patients who achieve partial improvement with an initial therapeutic class, clinicians should offer a trial of a medication from a different effective class or combination therapy by adding a medication from a different effective class (Level B). ➤ Clinicians should NOT use opioids for the treatment of painful diabetic neuropathy (Level B). ➤ If patients are currently on opioids for the treatment of painful diabetic neuropathy, clinicians may offer the option of a safe taper off these medications and discuss alternative nonopioid treatment strategies (Level C). ➤ Clinicians should NOT use tramadol and tapentadol (opioids/SNRI dual mechanism agents) for the treatment of painful diabetic neuropathy (Level C). ➤ If patients are currently on tramadol and tapentadol (opioids/SNRI dual mechanism agents) for the treatment of painful diabetic neuropathy, clinicians may offer the option of a safe taper off these medications and discuss alternative nonopioid treatment strategies (Level C).

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