Elsevier

Diabetes & Metabolism

Volume 35, Issue 1, February 2009, Pages 12-19
Diabetes & Metabolism

Review
Strategies for the diagnosis and treatment of neuropathic pain secondary to diabetic peripheral sensory polyneuropathyDouleurs neuropathiques de la polyneuropathie diabétique sensitive : stratégie diagnostique et thérapeutique

https://doi.org/10.1016/j.diabet.2008.09.003Get rights and content

Abstract

This article proposes a strategy for the diagnosis and treatment of neuropathic pain due to diabetic peripheral sensory neuropathy, based on 15 years of experience in French pain-management centres and on the available literature. In the diabetic patient with chronic pain in the lower limbs, the first step in the diagnostic process is to identify the neuropathic origin of the pain. The second step is to evaluate the patient's medical history and make a rigorous baseline assessment of the neuropathic pain symptoms to determine an effective pain-management strategy. In the third step, adequate and well-tolerated treatment directed towards a variety of painful symptoms is selected, taking into account other co-morbidities such as anxiety and depression. This report reports on the clinical aspects of neuropathic pain exhibited by patients with diabetic sensory polyneuropathy, and the key factors in their diagnosis and treatment, based on the results of meta-analyses and on a recent expert consensus.

Résumé

Nous proposons dans cet article des éléments de stratégie diagnostique et thérapeutique des douleurs neuropathiques de la polyneuropathie sensitive diabétique, à partir d’une solide expérience acquise dans les centres français de prise en charge de la douleur et sur la base des données de la littérature. Chez un patient diabétique souffrant de douleurs des membres inférieurs, la première étape de la démarche diagnostique consiste à identifier l’origine neuropathique des douleurs. L’évaluation du patient porte ensuite sur un recueil soigneux de ses antécédents et sur un examen clinique rigoureux, permettant de lui proposer une prise en charge adaptée et un traitement efficace. Le traitement retenu tient compte à la fois du type de symptômes douloureux présentés par le patient, du profil de tolérance du médicament et de l’existence de pathologies associées telles qu’un trouble anxieux ou dépressif. Les différentes caractéristiques cliniques des douleurs neuropathiques du diabétique sont illustrées dans cet article. Enfin, des repères diagnostiques et thérapeutiques sont proposés, s’appuyant sur les résultats de méta-analyses et sur les recommandations récentes des comités d’experts.

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.

References (50)

  • M.C. Rowbotham

    What is a “clinically meaningful” reduction in pain?

    Pain

    (2001)
  • J.T. Farrar et al.

    Defining the clinically important difference in pain outcome measures

    Pain

    (2000)
  • A.M. Gutierrez-Alvarez et al.

    Antiepileptic drugs in treatment of pain caused by diabetic neuropathy

    J Pain Symptom Manage

    (2007)
  • C.P. Watson et al.

    Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy

    Pain

    (2003)
  • S.J. Benbow et al.

    Painful diabetic neuropathy

    Diabet Med

    (1999)
  • A.J. Boulton et al.

    Diabetic neuropathies: a statement by the American Diabetes Association

    Diabetes Care

    (2005)
  • S.J. Benbow et al.

    A prospective study of painful symptoms, small-fibre function and peripheral vascular disease in chronic painful diabetic neuropathy

    Diabet Med

    (1994)
  • C. Daousi et al.

    Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes

    Diabet Med

    (2004)
  • R.H. Dworkin

    An overview of neuropathic pain: syndromes, symptoms, signs, and several mechanisms

    Clin J Pain

    (2002)
  • R.A. Malik et al.

    Sural nerve fibre pathology in diabetic patients with mild neuropathy: relationship to pain, quantitative sensory testing and peripheral nerve electrophysiology

    Acta Neuropathol

    (2001)
  • L. Sorensen et al.

    The relationship among pain, sensory loss, and small nerve fibers in diabetes

    Diabetes Care

    (2006)
  • L. Sorensen et al.

    The level of small nerve fiber dysfunction does not predict pain in diabetic neuropathy: a study using quantitative sensory testing

    Clin J Pain

    (2006)
  • S.T. Britland et al.

    Association of painful and painless diabetic polyneuropathy with different patterns of nerve fiber degeneration and regeneration

    Diabetes

    (1990)
  • M.C. Spruce et al.

    The pathogenesis and management of painful diabetic neuropathy: a review

    Diabet Med

    (2003)
  • N. Attal et al.

    Mechanisms of pain in peripheral neuropathy

    Acta Neurol Scand Suppl

    (1999)
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