A new look for the management of Painful Peripheral Neuropathy in Diabetes

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes that affects a large number of patients. DPN represent a paradox, at one extreme we can find patients with severe neuropathic pain but with minimal neurological deficit. At the other extreme are asymptomatic patients with insensate feet. Pain is very distressing symptom for the patient and also challenging for the treating physician.  Excluding other causes of pain is essential before attributing pain to neuropathy. Also Neuropathic pain could be due to causes other than diabetes.    Management of painful neuropathy should be more than just using pain alleviating modalities and a more comprehensive approach is needed.  We have to measure the severity of pain and its impact on quality of life.  The stability rather than the actual level of glycemic control may be more important in relieving neuropathic pain especially in its early stages. First line treatment for painful neuropathies are: Tricyclic antidepressant, Serotonin– noradrenalin reuptake inhibitors and Alpha-2-delta agonists.  Non-pharmacological interventions e.g. transcutaneous electrical nerve stimulation still need more evidence. Foot care is essential to protect the foot that lost its protective mechanisms. Identification and treatment of risk factors for IHD may save not only limbs but also lives.