Table 1.
Pharmacotherapy for Painful Diabetic Neuropathy.
| Dose range | Starting dose | Dose escalation | Mechanism | Side effects | Notes | |
|---|---|---|---|---|---|---|
| Pregabalin | 150-600 mg | 75 mg bid | Escalate to 150 mg bid within 1 week of initiation based on
tolerability; Max Dose: 300 mg bid |
Inhibition of voltage gated calcium channel and ATP gated potassium channel | Dizziness, blurred vision, drowsiness. | NNT = 5-8; NNH = 9-16 |
| Gabapentin | 300-3600 mg | 300 mg daily (Day 1) | Day 2: 300 mg bid; Day 3: 300 mg tid; Max Dose: 1800-3600 mg/day in 3 divided doses. |
Inhibition of voltage gated calcium channel | Confusion, dizziness, gastrointestinal issues, abnormal thinking | NNT = 3; NNH = 4 |
| Duloxetine | 60-120 mg | 30 mg bid | Lower dose based on tolerability. Max Dose: 60 mg/day. |
SNRI | Gastrointestinal issues, somnolence, hyperhidrosis | NNT = 5; NNH = 17 |
| Venlafaxine | 37.5-225 mg | 37.5 mg bid | Escalate to 150 mg daily: Max Dose: 225 mg daily |
SNRI or SSRI at low doses | Gastrointestinal issues, somnolence, hyperhidrosis, prolonged QT | NNT = 3; NNH = 16 |
| Amitriptyline | 10-150 mg | 10 mg daily at bedtime |
Max Dose: 150 mg daily at bedtime |
Inhibition of voltage-gated sodium channels, NDMA receptors, and reuptake of serotonin and norepinephrine | Gastrointestinal issues, orthostatic hypotension, dry mouth, urinary retention, and QTc prolongation. | NNT = 1-3; NNH = 28 (for major adverse effects), 6 (for minor adverse effects) |
| Tapentadol | 100-250 mg | 50 mg bid | Escalate to 100-250 mg bid as tolerated; Max Dose: 250 mg bid |
µ-opioid receptor agonist and norepinephrine reuptake inhibitor | Addiction, paradoxical hyperalgesia, respiratory depression, gastrointestinal issues. | NNT = 9-10; NNH = 5 |
| Topical Capsaicin | 0.075-8% | Apply 4 times daily | Not applicable | Vanilloid receptor agonist | Burning sensation and dermal irritation | NNT = 7 |
| Topical Lidocaine | 5% | 1 patch every 12 hours | 12-hour patch free interval. Max Dose: 3 patches daily |
Inhibition of voltage gated sodium channels. | Dermal irritation | NNT = 4 |
| α-Lipoic acid | 100-1800 mg | 600 mg | Not applicable | Antioxidant | Nausea, gastrointestinal issues | Not studied. |
| Actovegin | 600- 2000 mg | 600 mg tid | Not applicable | Anti-hypoxic agent | Nausea | Not studied. |
Abbreviations: bid, twice daily; NNH, number needed to harm; NNT, number needed to treat; SNRI, selective norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitors; tid, thrice daily.