Painful neuropathy

Up to 50% of patients with distal symmetrical polyneuropathy (peripheral neuropathy) experience pain, but the pain is often not severe enough to warrant treatment. Exclude other causes of painful neuropathy (eg vitamin B12 deficiency, myeloma) before starting treatment.

Drug treatment may relieve symptoms of painful diabetic neuropathy (eg lessen paraesthesia and pain) and improve sleep. Suitable regimens are:

1 amitriptyline 25 mg orally, at night, slowly increasing according to response up to maximum 150 mg at night neuropathic pain, diabetic amitriptyline    

OR

2 duloxetine 60 mg orally, daily, slowly increasing according to response up to maximum 60 mg twice daily neuropathic pain, diabetic duloxetine    

OR

2 gabapentin 300 mg orally, daily, slowly increasing according to response up to maximum 1200 mg 3 times daily neuropathic pain, diabetic gabapentin    

OR

2 pregabalin 75 mg orally, twice daily, slowly increasing according to response up to maximum 300 mg twice daily. neuropathic pain, diabetic pregabalin    

Adverse drug effects limit the use of oral treatment in many patients; slow increases in dose may help to minimise adverse effects and improve tolerability of the drug. Lower starting doses may be considered for older patients.

If oral therapy is not tolerated or is inadequate, capsaicin cream may be considered. For cases of painful neuropathy that are difficult to manage, seek expert advice. Polypharmacy is often required to achieve acceptable pain relief.