ReviewStrategies for the diagnosis and treatment of neuropathic pain secondary to diabetic peripheral sensory polyneuropathyDouleurs neuropathiques de la polyneuropathie diabétique sensitive : stratégie diagnostique et thérapeutique
Introduction
Patients with diabetes suffer from a number of painful conditions during the course of the disease, among which neuropathic pain is one of the most common and disabling [1], [2]. The clinical presentation of neuropathic pain secondary to diabetic peripheral sensory polyneuropathy is disconcerting and often misleading. Pain symptoms usually occur in association with neuropathic lesions, but they follow an unpredictable pattern of evolution as they develop independently of the severity of the neuropathy and can persist over years [2].
During the past 10 years, increasing scientific interest in pain syndromes has helped practitioners to overcome difficulties in managing patients with neuropathic pain [2]. The assessment of neuropathic pain syndromes, whatever their aetiology, has been facilitated by screening and diagnostic instruments that can easily be used in routine clinical practice. In addition, new pharmacological agents have been developed to treat neuropathic pain, some of which have been specifically tested in polyneuropathic pain due to diabetes. A number of therapeutic options are now available for patients with neuropathic pain, including those with long-standing diabetes who receive polytherapy and suffer from a number of co-morbidities [3], [4].
In this report, we present strategies for the diagnosis and treatment of pain secondary to diabetic sensory polyneuropathy, based on the current state of knowledge of neuropathic pain, and in the light of our own experience as neurologists and pain specialists in French pain-management centres.
Section snippets
General considerations
Neuropathic pain secondary to diabetic sensory polyneuropathy is typically polymorphous. Pain symptoms usually occur with the onset of polyneuropathy and fluctuate for years, independently of the extent of neuropathic lesions. Indeed, there is no correlation between the intensity of pain symptoms and the severity of sensory deficit.
The prevalence of painful neuropathy is estimated to be 10–15% of patients with diabetes [5], [6]. In half of these, pain symptoms are initially experienced together
Diabetes therapy
It is now well established that rigorous glycaemic control reduces the risk of peripheral sensory neuropathy and that regular assessment of polyneuropathy, once it is diagnosed, will slow the progression of the complication [2]. However, there are no data demonstrating that preventative or potentially curative measures can reduce the incidence of neuropathic pain in diabetic patients [25]. It is suggested that appropriate control of diabetes and prevention of diabetes complications may well
Conclusion
In the diabetic patient with sensory polyneuropathy, neuropathic pain is usually independent of the severity of the neuropathic lesion. The intensity of pain is greatly influenced by the patient's affective (emotional) state. Identification of the neuropathic source of the pain is based on the patient's clinical examination, although practical tools such as the DN4 questionnaire can help practitioners in their clinical analyses. Once the neuropathic origin of the pain has been diagnosed,
Conflict of interest
Dr Guastella has participated in clinical trials and been retained as a consultant for Pfizer. Dr Mick has participated in clinical trials and been a consultant for Eli Lilly, Pfizer, Grünenthal, Janssen-Cilag, Glaxo Wellcome, Astra Zeneca, Wyeth and Amirall.
Acknowledgements
The authors thank Dr C. Soubrouillard for her assistance in the preparation of this manuscript.
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