Fighting neuropathic pain: finding the right tools for the job

For people with painful diabetic neuropathy, turning off the pain completely is usually not a realistic option, says Professor Solomon Tesfaye in his latest EASD e-Learning module. But don’t let that stop you from pursuing maximum pain relief as aggressively as possible.

After several decades working in the field of diabetic neuropathy, Professor Solomon Tesfaye is all too aware of the heavy burden borne by people with the condition. “Painful diabetic neuropathy negatively impacts everything that you and I take for granted,” he says.

As Solomon sets out, these negative impacts include not just the active symptoms of neuropathy – the stabbing pains, burning sensations, feeling like you’re treading on broken glass. Compounding these are associated effects on mood (a study Solomon and his colleagues did in at Sheffield University showed that around 50% of people with the condition had mood disorder, anxiety and/or depression). There are the consequences for mobility and energy too. And then there’s the loss of sleep – a particularly brutal blow, says Solomon: “Loss of sleep makes you lose that reserve you need to fight the pain. So the patient is in the middle of all these self-enforcing triads – and the end result is reduction in functionality.”

Clearly then, even if turning off the pain completely is not a realistic treatment goal in most cases, the “aggressive pursuit of maximum relief” is vital. And it’s increasingly urgent. “We have around 4-5 million people with diabetes in the UK,” Solomon points out. “And one in four people have painful diabetic neuropathy.”

So far, so clear. But which of the treatments currently available deliver maximum relief for people with painful diabetic neuropathy? This module is particularly fascinating on that question – historically a knotty question, a fact Solomon attributes in part to problems with the way past research has been conducted in this area. “Many of the trials have been done on relatively healthy diabetes patients. Also, RCTs use forced titration despite side effects. That doesn’t happen in clinical practice. And some people have done combination trials from the start – you cannot do combination trials from the start. So a lot of these trials that have been done previously have been flawed. They have not looked at clinical practice.”

For a trial on the topic that would be readily generalisable and applicable upon completion, he identifies four key questions. Is low-dose combination therapy of the four first-line drugs better than a maximum dose of a monotherapy? Next, are maximum-tolerated doses of first-line agents better than maximum-tolerated doses of a combination of drugs? Thirdly, which is the best first-line drug? And finally, is there a best combination first-line drug?

These are the questions addressed by Solomon and his colleagues in the OPTION-DM. For more on the results from that trial and other recent trials that can help guide us to better pain management in painful diabetic neuropathy, enrol on Solomon’s new module, launching today.

Click here to access Professor Tesfaye’s new module, ‘Management of painful diabetic neuropathy’.

Any opinions expressed in this article are the responsibility of EASD e-Learning Programme Director, Dr Eleanor D Kennedy.