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Quiroz-Aldave J, Durand-Vásquez M, Gamarra-Osorio E, Suarez-Rojas J, Jantine Roseboom P, Alcalá-Mendoza R, Coronado-Arroyo J, Zavaleta-Gutiérrez F, Concepción-Urteaga L, Concepción-Zavaleta M. Diabetic neuropathy: Past, present, and future. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:153-169. [PMID: 37223297 PMCID: PMC10201131 DOI: 10.22088/cjim.14.2.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/03/2022] [Accepted: 09/06/2022] [Indexed: 05/25/2023]
Abstract
Background A sedentary lifestyle and an unhealthy diet have considerably increased the incidence of diabetes mellitus worldwide in recent decades, which has generated a high rate of associated chronic complications. Methods A narrative review was performed in MEDLINE, EMBASES and SciELO databases, including 162 articles. Results Diabetic neuropathy (DN) is the most common of these complications, mainly producing two types of involvement: sensorimotor neuropathy, whose most common form is symmetric distal polyneuropathy, and autonomic neuropathies, affecting the cardiovascular, gastrointestinal, and urogenital system. Although hyperglycemia is the main metabolic alteration involved in its genesis, the presents of obesity, dyslipidemia, arterial hypertension, and smoking, play an additional role in its appearance. In the pathophysiology, three main phenomena stand out: oxidative stress, the formation of advanced glycosylation end-products, and microvasculature damage. Diagnosis is clinical, and it is recommended to use a 10 g monofilament and a 128 Hz tuning fork as screening tools. Glycemic control and non-pharmacological interventions constitute the mainstay of DN treatment, although there are currently investigations in antioxidant therapies, in addition to pain management. Conclusions Diabetes mellitus causes damage to peripheral nerves, being the most common form of this, distal symmetric polyneuropathy. Control of glycemia and comorbidities contribute to prevent, postpone, and reduce its severity. Pharmacological interventions are intended to relieve pain.
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Affiliation(s)
| | | | | | | | - Pela Jantine Roseboom
- Division of Emergency Medicine, Hospital Regional Docente de Trujillo, Trujillo, Peru
| | - Rosa Alcalá-Mendoza
- Division of Physical Medicine and Rehabilitation, Hospital Víctor Lazarte Echegaray, Trujillo, Peru
| | - Julia Coronado-Arroyo
- Division of Obstetrics and Gynecology, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
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Silva Oggiam D, Vallim Jorgetto J, Chinini GL, Kusahara DM, Gamba MA. Distal Symmetric Polyneuropathy Pain in Diabetes Mellitus. AQUICHAN 2021. [DOI: 10.5294/aqui.2021.21.3.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: To evaluate neuropathic pain (NP), its intensity, and complications in people with type 2 diabetes mellitus (T2DM) in a city of eastern São Paulo.
Method: Cross-sectional study conducted with 96 individuals with T2DM served by primary health units in São João da Boa Vista-SP. The following instruments were used to screen NP: Michigan Neuropathy Screening Instrument, Leeds Assessment of Neuropathic Symptoms and Signs, Douleur Neuropathique 4, and Brief Pain Inventory. The data were analyzed using descriptive and inferential statistics, with a 5 % significance level.
Results: Of the 96 people with T2DM for longer than five years, 22.9 % had pain. NP was related to high levels of fasting blood glucose (mean = 214 ± 65.58 mg/dl; p = 0.0002), glycated hemoglobin (mean = 8.8 ± 0.11 %; p < 0.001), absence of a balanced diet (p = 0.0066), obesity (p = 0.023), and high blood pressure (p < 0.001).
Conclusion: Higher values of glycated hemoglobin rates increased three times the chance of NP. The screening and management of painful diabetic neuropathy is a challenge but adopting a screening protocol supports the secondary prevention of this manifestation.
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Marshall A, Alam U, Themistocleous A, Calcutt N, Marshall A. Novel and Emerging Electrophysiological Biomarkers of Diabetic Neuropathy and Painful Diabetic Neuropathy. Clin Ther 2021; 43:1441-1456. [PMID: 33906790 DOI: 10.1016/j.clinthera.2021.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes. Small and large peripheral nerve fibers can be involved in DPN. Large nerve fiber damage causes paresthesia, sensory loss, and muscle weakness, and small nerve fiber damage is associated with pain, anesthesia, foot ulcer, and autonomic symptoms. Treatments for DPN and painful DPN (pDPN) pose considerable challenges due to the lack of effective therapies. To meet these challenges, there is a major need to develop biomarkers that can reliably diagnose and monitor progression of nerve damage and, for pDPN, facilitate personalized treatment based on underlying pain mechanisms. METHODS This study involved a comprehensive literature review, incorporating article searches in electronic databases (Google Scholar, PubMed, and OVID) and reference lists of relevant articles with the authors' substantial expertise in DPN. This review considered seminal and novel research and summarizes emerging biomarkers of DPN and pDPN that are based on neurophysiological methods. FINDINGS From the evidence gathered from 145 papers, this submission describes emerging clinical neurophysiological methods with potential to act as biomarkers for the diagnosis and monitoring of DPN as well as putative future roles as predictors of response to antineuropathic pain medication in pDPN. Nerve conduction studies only detect large fiber damage and do not capture pathology or dysfunction of small fibers. Because small nerve fiber damage is prominent in DPN, additional biomarkers of small nerve fiber function are needed. Activation of peripheral nociceptor fibers using laser, heat, or targeted electrical stimuli can generate pain-related evoked potentials, which are an objective neurophysiological measure of damage along the small fiber pathways. Assessment of nerve excitability, which provides a surrogate of axonal properties, may detect alterations in function before abnormalities are detected by nerve conduction studies. Microneurography and rate-dependent depression of the Hoffmann-reflex can be used to dissect underlying pain-generating mechanisms arising from the periphery and spinal cord, respectively. Their role in informing mechanistic-based treatment of pDPN as well as facilitating clinical trials design is discussed. IMPLICATIONS The neurophysiological methods discussed, although currently not practical for use in busy outpatient settings, detect small fiber and early large fiber damage in DPN as well as disclosing dominant pain mechanisms in pDPN. They are suited as diagnostic and predictive biomarkers as well as end points in mechanistic clinical trials of DPN and pDPN.
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Affiliation(s)
- Anne Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Themistocleous
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Calcutt
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Andrew Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Neurophysiology, The Walton Centre, Liverpool, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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Jiang X, Yuan Y, Ma Y, Zhong M, Du C, Boey J, Armstrong DG, Deng W, Duan X. Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia. J Diabetes Res 2021; 2021:6699292. [PMID: 34046505 PMCID: PMC8128546 DOI: 10.1155/2021/6699292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022] Open
Abstract
Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.
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Affiliation(s)
- Xiaoyan Jiang
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yi Yuan
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yu Ma
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Miao Zhong
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Chenzhen Du
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Johnson Boey
- Department of Podiatry, National University of Hospital Singapore, Singapore 169608
| | - David G. Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Wuquan Deng
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Xiaodong Duan
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
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Naranjo C, Dueñas M, Barrera C, Moratalla G, Failde I. Sleep Characteristics in Diabetic Patients Depending on the Occurrence of Neuropathic Pain and Related Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218125. [PMID: 33153196 PMCID: PMC7663768 DOI: 10.3390/ijerph17218125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 12/11/2022]
Abstract
This study aims to compare the sleep characteristics (structure and quality) in patients with type-2 diabetes mellitus with and without diabetic neuropathic pain (DNP), and to investigate the relationship of sensory phenotypes, anxiety, and depression with sleep quality in DNP patients. A cross-sectional study was performed in patients with type-2 diabetes mellitus and neuropathy. Patients were classified into two groups—with or without neuropathic pain—according to the “Douleur Neuropathique-4 (DN4)” scale. Sleep characteristics and quality (Medical Outcomes Study—MOS-sleep), pain phenotype (Neuropathic Pain Symptom Inventory—NPSI), mood status (Hospital Anxiety and Depression scale—HADS), pain intensity (Visual Analogue Scale—VAS), and quality of life (SF-12v2) were measured. The sample included 130 patients (65 with DNP). The mean scores in all the dimensions of the MOS-sleep scale were higher (more disturbances) in the DNP patients. Higher scores in anxiety or depression, greater intensity of pain or a higher score in the paroxysmal pain phenotype were associated with lower sleep quality in DNP patients. A shorter duration of the diabetes and lower levels of glycated hemoglobin were also associated with lower sleep quality. The results show the relationship between DNP and sleep quality, and the importance of assessing sensory phenotypes and mental comorbidities in these patients. Taking these factors into consideration, to adopt a multimodal approach is necessary to achieve better clinical results.
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Affiliation(s)
- Cristina Naranjo
- University Hospital Puerta del Mar, Avda. Ana de Viya 21, 1009 Cádiz, Spain; (C.N.); (C.B.)
| | - María Dueñas
- Department of Statistics and Operational Research, University of Cadiz, Calle Enrique Villegas Vélez, 2, 11002 Cádiz, Spain
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Avda. Ana de Viya 21, 11009 Cádiz, Spain;
- The Observatory of Pain (External Chair of Pain), Grünenthal Foundation, University of Cádiz, Avda. Ana de Viya 52, 11009 Cádiz, Spain
- Correspondence: ; Tel.: +34-956019025
| | - Carlos Barrera
- University Hospital Puerta del Mar, Avda. Ana de Viya 21, 1009 Cádiz, Spain; (C.N.); (C.B.)
| | - Guillermo Moratalla
- Primary Care Center Loreto-Puntales, Health district Bahía de Cádiz-La Janda, C/ Hidroavión Numancia 0, 11011 Cádiz, Spain;
| | - Inmaculada Failde
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Avda. Ana de Viya 21, 11009 Cádiz, Spain;
- The Observatory of Pain (External Chair of Pain), Grünenthal Foundation, University of Cádiz, Avda. Ana de Viya 52, 11009 Cádiz, Spain
- Preventive Medicine and Public Health Area, University of Cádiz, Avda. Ana de Viya 52, 11009 Cádiz, Spain
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An orthopaedist’s review of diabetic foot wounds and osteomyelitis. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alam U, Sloan G, Tesfaye S. Treating Pain in Diabetic Neuropathy: Current and Developmental Drugs. Drugs 2020; 80:363-384. [DOI: 10.1007/s40265-020-01259-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Dorsey SG, Kleckner IR, Barton D, Mustian K, O'Mara A, St Germain D, Cavaletti G, Danhauer SC, Hershman DL, Hohmann AG, Hoke A, Hopkins JO, Kelly KP, Loprinzi CL, McLeod HL, Mohile S, Paice J, Rowland JH, Salvemini D, Segal RA, Smith EL, Stevens WM, Janelsins MC. The National Cancer Institute Clinical Trials Planning Meeting for Prevention and Treatment of Chemotherapy-Induced Peripheral Neuropathy. J Natl Cancer Inst 2020; 111:531-537. [PMID: 30715378 DOI: 10.1093/jnci/djz011] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/04/2019] [Accepted: 01/25/2019] [Indexed: 12/25/2022] Open
Abstract
Although recent scientific advances have improved our understanding of basic biological mechanisms underlying chemotherapy-induced peripheral neuropathy (CIPN), few interventions are available to prevent or treat CIPN. Although some biological targets from preclinical studies show promise in nonhuman animal models, few targets have been translated to successful clinical trials. To address this problem, the National Cancer Institute's Symptom Management and Health-Related Quality of Life Steering Committee convened a meeting of experts in the CIPN and oncology symptom management fields to participate in a Clinical Trials Planning Meeting (CTPM). Investigators presented data from preclinical and translational studies for possible CIPN interventions; these were evaluated for readiness of randomized clinical trial testing by experts, and recommendations were provided. Breakout sessions were convened to discuss and develop future studies. The CTPM experts concluded that there is compelling evidence to move forward with selected pharmacological and nonpharmacological clinical trials for the prevention and treatment of CIPN. Several key feasibility issues need to be addressed, however. These include identification of optimal outcome measures to define the CIPN phenotype, establishment of parameters that guide the evaluation of clinically meaningful effects, and adoption of approaches for inclusion of translational and biomarker and/or genetic measures. The results of the CTPM provide support for conducting clinical trials that include both pharmacological and nonpharmacological approaches, alone or in combination, with biomarkers, genetics, or other measures designed to inform underlying CIPN mechanisms. Several working groups were formed to design rigorous CIPN clinical trials, the results of which are ongoing.
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Affiliation(s)
- Susan G Dorsey
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Center to Advance Chronic Pain Research, Baltimore, MD
| | - Ian R Kleckner
- Department of Surgery, University of Rochester Medical Center, Cancer Control Program, Wilmot Cancer Institute, Rochester, NY
| | - Debra Barton
- University of Michigan School of Nursing, Ann Arbor, MI
| | - Karen Mustian
- Department of Surgery, University of Rochester Medical Center, Cancer Control Program, Wilmot Cancer Institute, Rochester, NY
| | - Ann O'Mara
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Diane St Germain
- Division of Cancer Prevention, National Cancer Institute, Bethesda, MD
| | - Guido Cavaletti
- Experimental Neurology Unit, School of Medicine and Surgery, University Milano-Bicocca, Monza, Italy
| | - Suzanne C Danhauer
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston Salem, NC
| | - Dawn L Hershman
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Andrea G Hohmann
- Department of Psychological and Brain Sciences, Program in Neuroscience and Gill Center for Biomolecular Science, Indiana University, Bloomington, IN
| | - Ahmet Hoke
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - Katherine P Kelly
- Children's National Health System, Department of Nursing Science, Professional Practice, and Quality, George Washington School of Medicine and Health Sciences, Washington, DC
| | | | | | - Supriya Mohile
- Department of Surgery, University of Rochester Medical Center, Cancer Control Program, Wilmot Cancer Institute, Rochester, NY
| | - Judith Paice
- Hematology-Oncology Division, Northwestern University, Chicago, IL
| | | | - Daniela Salvemini
- Department of Pharmacology and Physiology, Saint Louis University School of Medicine, St. Louis, MO
| | - Rosalind A Segal
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Michelle C Janelsins
- Department of Surgery, University of Rochester Medical Center, Cancer Control Program, Wilmot Cancer Institute, Rochester, NY
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Rolim LCSP, da Silva EMK, Flumignan RLG, Abreu MM, Dib SA. Acetyl-L-carnitine for the treatment of diabetic peripheral neuropathy. Cochrane Database Syst Rev 2019; 6:CD011265. [PMID: 31201734 PMCID: PMC6953387 DOI: 10.1002/14651858.cd011265.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetic peripheral neuropathy (DPN) is a common and severe complication that affects 50% of people with diabetes. Painful DPN is reported to occur in 16% to 24% of people with diabetes. A complete and comprehensive management strategy for the prevention and treatment of DPN, whether painful or not, has not yet been defined.Research into treatment for DPN has been characterised by a series of failed clinical trials, with few noteworthy advances. Strategies that support peripheral nerve regeneration and restore neurological function in people with painful or painless DPN are needed. The amino acid acetyl-L-carnitine (ALC) plays a role in the transfer of long-chain fatty acids into mitochondria for β-oxidation. ALC supplementation also induces neuroprotective and neurotrophic effects in the peripheral nervous system. Therefore, ALC supplementation targets several mechanisms relevant to potential nerve repair and regeneration, and could have clinical therapeutic potential. There is a need for a systematic review of the evidence from clinical trials. OBJECTIVES To assess the effects of ALC for the treatment of DPN. SEARCH METHODS On 2 July 2018, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We checked references, searched citations, and contacted study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of ALC compared with placebo, other therapy, or no intervention in the treatment of DPN. Participants could be of any sex and age, and have type 1 or type 2 diabetes mellitus, of any severity, with painful or painless DPN. We accepted any definition of minimum criteria for DPN, in accordance with the Toronto Consensus. We imposed no language restriction.Pain was the primary outcome, measured as the proportion of participants with at least 30% (moderate) or 50% (substantial) decrease in pain over baseline, or as the score on a visual analogue scale (VAS) or Likert scale for pain. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. MAIN RESULTS We included four studies with 907 participants, which were reported in three publications. Three trials studied ALC versus placebo (675 participants); in one trial the dose of ALC was 2000 mg/day, and in the other two trials, it was 1500 mg/day or 3000 mg/day. The fourth trial studied ALC 1500 mg/day versus methylcobalamin 1.5 mg/day (232 participants). The risk of bias was high in both trials of different ALC doses and low in the other two trials.No included trial measured the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. ALC reduced pain more than placebo, measured on a 0- to 100-mm VAS (MD -9.16, 95% CI -16.76 to -1.57; three studies; 540 participants; P = 0.02; I² = 56%; random-effects; very low-certainty evidence; a higher score indicating more pain). At doses of 1500 mg/day or less, the VAS score after ALC treatment was little different from placebo (MD -0.05, 95% CI -10.00 to 9.89; two studies; 159 participants; P = 0.99; I² = 0%), but at doses greater than 1500 mg/day, ALC reduced pain more than placebo (MD -14.93, 95% CI -19.16 to -10.70; three studies; 381 participants; P < 0.00001; I² = 0%). This subgroup analysis should be viewed with caution as the evidence was even less certain than the overall analysis, which was already of very low certainty.Two placebo-controlled studies reported that vibration perception improved after 12 months. We graded this evidence as very low certainty, due to inconsistency and a high risk of bias, as the trial authors did not provide any numerical data. The placebo-controlled studies did not measure functional impairment and disability scores. No study used validated symptom scales. One study performed sensory testing, but the evidence was very uncertain.The fourth included study compared ALC with methylcobalamin, but did not report effects on pain. There was a reduction from baseline to 24 weeks in functional impairment and disability, based on the change in mean Neuropathy Disability Score (NDS; scale from zero to 10), but there was no important difference between the ALC group (mean score 1.66 ± 1.90) and the methylcobalamin group (mean score 1.35 ± 1.65) groups (P = 0.23; low-certainty evidence).One placebo-controlled study reported that six of 147 participants in the ALC > 1500 mg/day group (4.1%) and two of 147 participants in the placebo group (1.4%) discontinued treatment because of adverse events (headache, facial paraesthesia, and gastrointestinal disorders) (P = 0.17). The other two placebo-controlled studies reported no dropouts due to adverse events, and more pain, paraesthesia, and hyperaesthesias in the placebo group than the 3000 mg/day ALC group, but provided no numerical data. The overall certainty of adverse event evidence for the comparison of ALC versus placebo was low.The study comparing ALC with methylcobalamin reported that 34/117 participants (29.1%) experienced adverse events in the ALC group versus 33/115 (28.7%) in the methylcobalamin group (P = 0.95). Nine participants discontinued treatment due to adverse events (ALC: 4 participants, methylcobalamin: 5 participants), which were most commonly gastrointestinal symptoms. The certainty of the adverse event evidence for ALC versus methylcobalamin was low.Two studies were funded by the manufacturer of ALC and the other two studies had at least one co-author who was a consultant for an ALC manufacturer. AUTHORS' CONCLUSIONS We are very uncertain whether ALC causes a reduction in pain after 6 to 12 months' treatment in people with DPN, when compared with placebo, as the evidence is sparse and of low certainty. Data on functional and sensory impairment and symptoms are lacking, or of very low certainty. The evidence on adverse events is too uncertain to make any judgements on safety.
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Affiliation(s)
- Luiz CSP Rolim
- Universidade Federal de São PauloDepartment of Internal MedicineRua Borges Lagoa, 1065/110São PauloSão PauloBrazil04038‐032
| | - Edina MK da Silva
- Universidade Federal de São PauloEmergency Medicine and Evidence Based MedicineRua Borges Lagoa 564 cj 64Vl. ClementinoSão PauloSão PauloBrazil04038‐000
| | - Ronald LG Flumignan
- Universidade Federal de São PauloDepartment of Surgery, Division of Vascular and Endovascular SurgeryRua Borges Lagoa, 754São PauloSPBrazil04038‐001
| | - Marcio M Abreu
- Yale University School of MedicineAnaesthesiology and Critical Care Medicine333 Cedar Street, TMP 3P.O. Box 208051New HavenCTUSA06520‐8051
| | - Sérgio A Dib
- Universidade Federal de São PauloDepartment of Medicine / EndocrinologyRua Pedro de Toledo, 910São PauloSão PauloBrazil04038‐000
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Azmi S, ElHadd KT, Nelson A, Chapman A, Bowling FL, Perumbalath A, Lim J, Marshall A, Malik RA, Alam U. Pregabalin in the Management of Painful Diabetic Neuropathy: A Narrative Review. Diabetes Ther 2019; 10:35-56. [PMID: 30565054 PMCID: PMC6349275 DOI: 10.1007/s13300-018-0550-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Indexed: 12/18/2022] Open
Abstract
Pregabalin is a first-line treatment in all major international guidelines on the management of painful diabetic neuropathy (pDPN). Treatment with pregabalin leads to a clinically meaningful improvement in pain scores, offers consistent relief of pain and has an acceptable tolerance level. Despite its efficacy in relieving neuropathic pain, more robust methods and comprehensive studies are required to evaluate its effects in relation to co-morbid anxiety and sleep interference in pDPN. The sustained benefits of modulating pain have prompted further exploration of other potential target sites and the development of alternative GABAergic agents such as mirogabalin. This review evaluates the role of pregabalin in the management of pDPN as well as its potential adverse effects, such as somnolence and dizziness, which can lead to withdrawal in ~ 30% of long-term use. Recent concern about misuse and an increase in deaths linked to its use has led to demands for reclassification of pregabalin as a class C controlled substance in the UK. We believe these demands need to be tempered in relation to the difficulties it would create for repeat prescriptions for the many millions of patients with pDPN for whom pregabalin provides benefit.Plain Language Summary: Plain language summary available for this article.
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Affiliation(s)
- Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | | | - Andrew Nelson
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Adam Chapman
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Frank L Bowling
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Anughara Perumbalath
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Jonathan Lim
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Andrew Marshall
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
- Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK.
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Iqbal Z, Azmi S, Yadav R, Ferdousi M, Kumar M, Cuthbertson DJ, Lim J, Malik RA, Alam U. Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy. Clin Ther 2018; 40:828-849. [PMID: 29709457 DOI: 10.1016/j.clinthera.2018.04.001] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Diabetic peripheral neuropathy (DPN) is the commonest cause of neuropathy worldwide, and its prevalence increases with the duration of diabetes. It affects approximately half of patients with diabetes. DPN is symmetric and predominantly sensory, starting distally and gradually spreading proximally in a glove-and-stocking distribution. It causes substantial morbidity and is associated with increased mortality. The unrelenting nature of pain in this condition can negatively affect a patient's sleep, mood, and functionality and result in a poor quality of life. The purpose of this review was to critically review the current literature on the diagnosis and treatment of DPN, with a focus on the treatment of neuropathic pain in DPN. METHODS A comprehensive literature review was undertaken, incorporating article searches in electronic databases (EMBASE, PubMed, OVID) and reference lists of relevant articles with the authors' expertise in DPN. This review considers seminal and novel research in epidemiology; diagnosis, especially in relation to novel surrogate end points; and the treatment of neuropathic pain in DPN. We also consider potential new pharmacotherapies for painful DPN. FINDINGS DPN is often misdiagnosed and inadequately treated. Other than improving glycemic control, there is no licensed pathogenetic treatment for diabetic neuropathy. Management of painful DPN remains challenging due to difficulties in personalizing therapy and ascertaining the best dosing strategy, choice of initial pharmacotherapy, consideration of combination therapy, and deciding on defining treatment for poor analgesic responders. Duloxetine and pregabalin remain first-line therapy for neuropathic pain in DPN in all 5 of the major published guidelines by the American Association of Clinical Endocrinologists, American Academy of Neurology, European Federation of Neurological Societies, National Institute of Clinical Excellence (United Kingdom), and the American Diabetes Association, and their use has been approved by the US Food and Drug Administration. IMPLICATIONS Clinical recognition of DPN is imperative for allowing timely symptom management to reduce the morbidity associated with this condition.
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Affiliation(s)
- Zohaib Iqbal
- Department of Endocrinology, Pennine Acute Hospitals NHS Trust, Greater Manchester, United Kingdom
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom
| | - Rahul Yadav
- Department of Endocrinology, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, United Kingdom
| | - Maryam Ferdousi
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom
| | - Mohit Kumar
- Department of Endocrinology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Daniel J Cuthbertson
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Jonathan Lim
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Rayaz A Malik
- Institute of Cardiovascular Science, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, United Kingdom; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom; Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, United Kingdom; Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, United Kingdom.
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