What is the best treatment for diabetic neuropathy?

Journal of Family Practice, May, 2004

The Table characterizes the agents, the number of trials that address each, the NNT, NNH, typical effective dose, and approximate retail cost per month with the average effective dose.

* RECOMMENDATIONS FROM OTHERS

American Diabetes Association practice guidelines do not address neuropathy; UptoDate emphasizes prevention through glycemic control, with initial treatment using amitriptyline or nortriptyline, followed by capsaicin and anticonvulsants. (5)

TABLE
Efficacy of drug treatments for diabetic neuropathy

                       Number of     NNT (95% CI)
                       controlled    for 50% pain
Drug                     trials        reduction      NNH (95% CI)

Antidepressants            16        3.4 (2.6-4.7)    2.7 (2.1-3.9)

Tricyclics                 8         3.5 (2.5-5.6)    3.2 (2.3-5.2)

SSRIs                      3        Not efficacious

Anticonvulsants *          3         2.7 (2.2-3.8)    2.7 (2.2-3.4)

Phenytoin                  1         Not available    3.2 (2.1-6.3)

Carbamezapine              1         Not available    Not available

Gabapentin                 2         Not available    2.6 (2.1-3.3)

Valproate ([dagger])       1         Not available        Rare

Topical capsaicin          4          4(2.9-6.7)      Not available

Lidocaine patch            0         Not available    Not available

                                                  Typical
Drug                       Efficacious dose        cost

Antidepressants

Tricyclics             Amitryptiline                $12
                       50-100 mg/d;
                       Nortryptiline
                       50-75 mg/d

SSRIs                  N/A                          N/A

Anticonvulsants *

Phenytoin              300 mg/d                     $18

Carbamezapine          400 mg 2x daily              $28

Gabapentin             600-900 mg 3x daily         $333

Valproate ([dagger])   400 mg 3x daily              $36

Topical capsaicin      0.075% 4x daily              $39

Lidocaine patch        1 patch each foot, daily    $272

Costs based on 30 days of typical efficacious dose. Retail prices
from www.drugstore.com, December 2003, except for capsaicin, which
was obtained from Walmart.

* This summary does not include results from Kochar et al.

([dagger]) Data from this trial cannot be summarized within this
framework; however, results were statistically significant and similar
in magnitude to other trials.

NNT, number needed to treat; NNH, number needed to harm; CI, confidence
interval

REFERENCES

(1.) Collins SL, Moore RA, McQuayHJ, Wiffen P. Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review. J Pain Symptom Manage 2000; 20:449-458.

(2.) Kochar DK, Jain N, Agarwal RP, Srivastava T, Agarwal P, Gupta S. Sodium valproate in the management of painful neuropathy in type 2 diabetes--a randomized placebo controlled study. Acta Neurol Scand 2002; 106:248-252.

(3.) Zhang WY, Li Wan Po A. The effectiveness of topically applied capsaicin. A meta-analysis. Eur J Clin Pharmacol 1994; 46:517-522.