Treatment of diabetic neuropathy

The main measure for the prevention and treatment of diabetic neuropathy is achieving and maintaining target glycemic values.

Recommendations for pathogenetic therapy of diabetic neuropathy (benfotiamine, aldolase reductase inhibitors, thioctic acid, nerve growth factor, aminoguanidine, protein kinase C inhibitor) are in the development stage. In some cases, these drugs relieve neuropathic pain. Treatment of diffuse and focal neuropathies is mainly symptomatic.

Thioctic acid - intravenously by drip (over 30 minutes) 600 mg in 100-250 ml of 0.9% sodium chloride solution once a day, course 10-12 injections, then orally 600-1800 mg/day, in 1-3 doses, 2-3 months.

Benfotiamine - orally 150 mg, 3 times a day, 4-6 weeks.

Pain relief and anti-inflammatory therapy

For pain, in addition to NSAIDs, local anesthetics are used:

• Diclofenac orally, 50 mg 2 times a day, the duration of therapy is determined individually or
• Ibuprofen orally 600 mg 4 times a day, the duration of therapy is determined individually or
• Ketoprofen orally 50 mg 3 times a day, the duration of therapy is determined individually.
• Lidocaine 5% gel, apply locally in a thin layer to the skin up to 3-4 times a day, the duration of therapy is determined individually or
• Capsaicin, 0.075% ointment/cream, apply topically in a thin layer to the skin up to 3-4 times a day, the duration of therapy is determined individually.

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Antidepressant and anticonvulsant therapy

If NSAIDs are ineffective, antidepressants (tricyclic and tetracyclic, selective serotonin reuptake inhibitors) can have an analgesic effect:

• Amitriptyline orally 25-100 mg once a day (at night), the duration of therapy is determined individually.
• Maprotiline orally 25-50 mg 1-3 times a day (but not more than 150 mg/day), the duration of therapy is determined individually or
• Fluoxetine orally 20 mg 1-3 times a day (initial dose 20 mg/day, increase the dose by 20 mg/day in 1 week), the duration of therapy is determined individually or
• Citalopram orally 20-60 mg once a day, the duration of therapy is determined individually.

It is also possible to use anticonvulsant drugs:

• Gabapentin orally 300-1200 mg 3 times a day, the duration of therapy is determined individually or
• Carbamazepine orally 200-600 mg 2-3 times a day (maximum dose 1200 mg/day), the duration of therapy is determined individually.

Neurostimulation

Neurostimulation treatment methods (transcutaneous electrical nerve stimulation, spinal cord stimulation) are also used to relieve neuropathic pain.

Other treatment methods

Non-drug and drug treatment methods are used to treat autonomic diabetic neuropathy.

In case of autonomic neuropathy of the gastrointestinal tract, it is recommended to eat small portions of food; if there is a risk of developing postprandial hypoglycemia, it is advisable to drink a sugar-containing drink before eating. Medicines that normalize gastrointestinal motility are used; in case of gastric atony, antibiotics are additionally prescribed:

• Domperidop orally 10 mg 3 times a day, the duration of therapy is determined individually or
• Metoclopramide orally 5-10 mg 3-4 times a day, the duration of therapy is determined individually.
• Erythromycin orally 0.25-4 times a day, 7-10 days.

For diarrhea associated with diabetic enteropathy, broad-spectrum antibiotics and drugs that inhibit gastrointestinal motility are used:

• Doxycycline orally 0.1-0.2 g once a day, for 2-3 days monthly (in the absence of dysbacteriosis).
• Loperamide orally 2 mg, then 2-12 mg/day until stool frequency is 1-2 times a day, but not more than 6 mg/20 kg of patient body weight per day.

In case of autonomous diabetic neuropathy of the cardiovascular system with orthostatic hypotension, it is recommended to drink plenty of fluids, take a contrast shower, wear elastic stockings, and it is advisable to slightly increase the intake of table salt. The patient should get up slowly from the bed and chair. If such measures are unsuccessful, mineralocorticoid drugs are prescribed:

• Fludrocortisone orally 0.1-0.4 once a day, the duration of therapy is determined individually.

For heart rhythm disorders

Mexiletine orally 400 mg, then 200 mg every 8 hours, - after achieving the effect - 200 mg 3-4 times a day, the duration of therapy is determined individually.

When prescribing antiarrhythmic drug therapy, it is advisable to treat the patient in conjunction with a cardiologist.

In case of autonomic diabetic neuropathy with bladder dysfunction, catheterization and drugs that normalize detrusor function are used (treatment is carried out in conjunction with a urologist).

In case of erectile dysfunction, it is possible to use alprostadil according to standard regimens (in the absence of contraindications).

Surgical treatment

Patients with tunnel syndromes often have to resort to surgical treatment to decompress the nerve.

Evaluation of treatment effectiveness

The effectiveness of the treatment of diabetic neuropathy is evidenced by the relief of pain syndrome and the elimination of dysfunctions of internal organs caused by autonomic diabetic neuropathy.

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Errors and unjustified appointments

When prescribing NSAIDs, it is necessary to remember their possible nephrotoxic effect, while the absence of an analgesic effect does not require an increase in the dose of the drug, but an assessment of the reasons for the ineffectiveness of NSAIDs.

In our country, there is a tradition of widely using auxiliary drugs (water-soluble B vitamins, antioxidants, magnesium and zinc preparations) in the treatment of diabetes.

However, data from large international studies on the effectiveness of such drugs is insufficient, and most experts believe that additional international studies are needed on this issue. It should also be remembered that no auxiliary drug can replace good compensation for diabetes.

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Forecast

Diabetic neuropathy worsens the prognosis of patients with diabetes mellitus. This is especially true for autonomic diabetic neuropathy, damage to the autonomic innervation of the cardiovascular system increases the risk of ventricular arrhythmias (including ventricular tachycardia and ventricular fibrillation) by 4 times, and, accordingly, sudden death.

Compensation of diabetes mellitus - intensified insulin therapy, patient education and maintenance of good compensation of carbohydrate metabolism - reduces the risk of developing clinical and electrophysiological manifestations of peripheral neuropathy by approximately 50-56%. It has also been proven that maintaining normoglycemia, controlling blood cholesterol levels, blood pressure in combination with the use of angiotensin-converting enzyme inhibitors reduces the risk of developing autonomic diabetic neuropathy by approximately 3 times.

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