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New Guidelines Boast Benefits for Patients Suffering With DPN Pain

The ASPE issued a set of guidelines that provide a consistent
treatment strategy for this condition.

BY LAURA SUAREZ, MANAGING EDITOR

Guidelines aimed at the treatment of diabetic peripheral neuropathic (DPN) pain have been published in Mayo Clinic Proceedings. This first-ever set of criteria is expected to benefit patients with DPN pain through (1) decreasing or resolving their pain and (2) decreasing their chance of side effects from treatments.

The American Society of Pain Educators (ASPE) authored the DPN Pain Consensus Treatment Guidelines in order to offer a consistent DPN pain treatment strategy, improve outcomes of treatment and decrease the number of DPN-associated medical errors. Guidelines are intended for use among primary care physicians, pain practitioners and other professional practitioners who treat/help the population with diabetes.

NEED FOR GUIDELINES
“Although most patients with [DPN] rarely experience excruciating pain, enough do that we must have strategies and treatment options for addressing their pain,” wrote B. Eliot Cole, MD, MPA, executive director of the ASPE, in the guideline’s foreward. “As Americans age and live longer with diabetes, there is a need for DPN [pain] guidelines and for other pain-related conditions.”

A board of 11 pain specialists — the DPN Pain Consensus Treatment Guidelines Advisory Board (Table 1) — assembled for 2 days to decide upon recommendations for the treatment of DPN pain. The specialists based their recommendations on previously published neuropathy literature (eg, blinded, randomized, placebo-controlled clinical trials and off-label indication trials) and personal experience with pain-related treatments. From this review of the literature, the authors concluded that three categories were warranted to rank the treatments. These categories — first-tier (ie, treatments that showed strong support of decreasing DPN pain), second-tier (ie, treatment that showed strong support of decreasing other types of nerve damage pain but not DPN pain) and honorable mention — included treatments such as anticonvulsants, antidepressants and opioids. Table 2 shows the breakdown of treatments in each category.

MODIFYING TREATMENT FOR PATIENT RESPONSE
Treatment modification may also be a strategy when patients are not responding to their current medications. According to the authors, in the instance of a patient not responding to first-line treatment, the practitioner should first try another first-tier treatment that has a different mechanism of action. If this strategy is unsuccessful, the practitioner should then change to a second-tier treatment, again using the mechanism of action function to determine the treatment. Lastly, practitioners should try another first- or second-tier treatment that may increase patient response to treatment. Only in rare cases, the authors concluded, will a patient obtain complete relief of pain associated with DPN. Multiple treatments are often a necessity in patients with DPN pain.

Also included in the consensus guidelines is a general article exploring clinical and quality-of-life issues associated with DPN pain as well as case studies that identify ties between diabetes and its associated pain-related conditions. Both items may be used by practitioners to improve upon the care they offer to patients with DPN pain, according to Dr. Cole’s foreward. In the general article, the authors urge practitioners to build a relationship with and educate their patients about pain associated with DPN.

“A frank discussion of the benefits and limitations of the treatments used to control pain must include the understanding that patients may not achieve complete relief; however, the health care professional should assure the patient that together they will work to achieve the best possible results,” the authors wrote in Diabetic Peripheral Neuropathic Pain: Clinical and Quality-of-Life Issues. They also listed six key points for consideration:
• Patients with diabetes may also experience nondiabetic neuropathies;
• Many patients with DPN (≤50%) do not experience symptoms associated with this condition;
• Insensate foot injuries may still occur in those patients who do not experience symptoms;
• DPN pain puts patients at risk for medical and psychological comorbidities;
• Patients who experience pain associated with symptomatic DPN have various treatment options; and
• When patients are educated and take ownership in their care, there is a beneficial factor.

Eli Lilly and Company (Indianapolis, Ind) provided an educational grant for the development of the guidelines; Johns Hopkins University School of Medicine and the ASPE jointly sponsored the consensus guidelines, which were published as a continuing medical education supplement. For more information, visit www.mayoclinicproceedings.com.


Cole BE, Argoff CE, Fishbain DA, et al. Consensus Guidelines: Assessment, diagnosis, and treatment of diabetic peripheral neuropathic pain. Mayo Clinic Proceedings. 2006;81(suppl):S1-S32.
For a downloadable pdf of this article, including Tables and Figures, click here.