Treatment of diabetic neuropathy

The main measure of prevention and treatment of diabetic neuropathy is the achievement and maintenance of target values of glycemic values.

Recommendations for the pathogenetic therapy of diabetic neuropathy (benfotiamine, aldolazoreductase inhibitors, thioctic acid, nerve growth factor, aminoguanidine, protein kinase C inhibitor) are being developed. In some cases, these drugs alleviate neuropathic pain. Treatment of diffuse and focal neuropathies is mostly symptomatic.

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

Benfotiamin - inside 150 mg, 3 times a day, 4-6 weeks.

Anesthetic and anti-inflammatory therapy

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

• Diclofenac inside, 50 mg 2 times a day, the duration of therapy is determined individually or
• Ibuprofen 600 mg 4 times a day, the duration of therapy is determined individually or
• Ketoprofen is administered 50 mg 3 times a day, the duration of therapy is determined individually.
• Lidocaine 5% gel, topically apply a thin layer on the skin 3-4 times a day, the duration of therapy is determined individually or
• Capsaicin, 0,075% ointment / cream, topically apply a thin layer on the skin 3-4 times a day, the duration of therapy is determined individually.

[1], [2], [3], [4]

Therapy with antidepressants and anticonvulsants

In case of ineffectiveness of NSAIDs, analgesic effect may be exerted by antidepressants (tricyclic and tetracyclic, selective serotonin reuptake inhibitors):

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

It is also possible to use anticonvulsant drugs:

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

Neuro-stimulation

Neuropathic pain treatment methods (percutaneous electrical stimulation of the nerve, stimulation of the spinal cord) are also used to arrest neuropathic pains.

Other treatments

For the treatment of autonomic diabetic neuropathy, non-drug and medicamental methods of treatment are used.

With autonomic neuropathy, the gastrointestinal tract is recommended to eat in small portions, in case of the risk of developing postprandial hypoglycemia, it is advisable to drink a sugar-containing beverage before eating. Use drugs that normalize the motility of the gastrointestinal tract, with atony of the stomach, antibiotics are additionally prescribed:

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

With diarrhea associated with diabetic enteropathy, antibiotics of a wide range of action and preparations that inhibit the motility of the gastrointestinal tract are used:

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

With autonomic diabetic neuropathy cardiovascular system with orthostatic hypotension recommend abundant drinking, contrast shower, wearing elastic stockings, it is advisable to slightly increase the intake of edible salt. From the bed and chair, the patient needs to get up slowly. If such measures are unsuccessful, mineralocorticoid preparations are prescribed:

• Fludrocortisone inside 0.1-0.4 1 time per day, the duration of therapy is determined individually.

With heart rhythm disturbances

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

When administering antiarrhythmic drugs, it is advisable to treat the patient together with a cardiologist.

With autonomous diabetic neuropathy with a violation of the function of the bladder, catheterization is used, drugs that normalize detrusor function (treatment is carried out together with the urologist).

With erectile dysfunction, it is possible to use alprostadil according to standard schemes (in the absence of contraindications).

Operative treatment

Patients with tunnel syndromes often have to resort to surgical treatment for the purpose of decompression of the nerve.

Evaluation of treatment effectiveness

The effectiveness of the treatment of diabetic neuropathy is indicated by the relief of the pain syndrome, the elimination of violations of the functions of internal organs caused by autonomic diabetic neuropathy.

[5], [6], [7], [8], [9], [10]

Errors and unreasonable appointments

When NSAIDs are prescribed, it is necessary to remember about 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 causes of inefficiency of NSAIDs.

In our country there is a tradition of widespread use in the treatment of diabetes mellitus ancillary drugs (water-soluble B vitamins, antioxidants, magnesium and zinc preparations).

Nevertheless, data from major international studies on the effectiveness of such drugs are not enough, and, according to most experts, additional international research is needed on this issue. It should also be remembered that no auxiliary drug can replace good compensation for diabetes.

[11], [12]

Forecast

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

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

[13]