A 64-year-old woman comes to the physician because she has had bilateral foot numbness and burning for the past three months. The symptoms are especially bothersome at night. She has a history of hypertension, coronary artery disease, and type 2 diabetes mellitus. She had an anterior wall myocardial infarction two years ago, which was treated with angioplasty and stenting of the left anterior descending artery. An echocardiogram obtained one year ago revealed an ejection fraction of 40%. She does not use tobacco, alcohol, or drugs. Her medications include metoprolol, furosemide, glyburide, atorvastatin, aspirin, and enalapril. She has been on oral hypoglycemic medications for the last ten years. Her blood pressure is 142/82 mmHg and her heart rate is 63/min. Her BMI is 34 kg/m². Physical examination shows intact skin over both feet and 2+ peripheral pulses. The patient returns two months later for follow-up. She has persistent symptoms and complains of poor sleep. Her last HbA1c was 7.9% and creatinine was 0.9 mg/dL. Urinalysis shows trace proteinuria. Which of the following is the best management option for this patient?

Question

Quizplus · Accepted Answer

Explanation: The most important aspect of management of diabetic neuropathy is aggressive glycemic control, which is still needed in this patient given that her HbA1c is above the goal level of 7.0%. However, some patients with diabetic neuropathy do experience a severe burning sensation that can interfere with sleep, necessitating some form of pain control. A variety of agents may be used to treat the pain of diabetic neuropathy. First-line agents include duloxetine (serotonin norepinephrine reuptake inhibitor - SNRI), pregabalin, and tricyclic antidepressants. All of these agents interfere with the neural transmission of pain. Other agents that are frequently used include the anticonvulsant medications gabapentin, lamotrigine, and carbamazepine. Topical treatments such as capsaicin cream and topical lidocaine can also be considered for some patients. Pain symptoms of diabetic neuropathy often spontaneously resolve within a year, so eventual discontinuation of these medications is often possible. (Choice B) Opioid medications are often less effective at controlling the neuropathic pain of diabetic neuropathy. While they can be used alone or in combination with other medications, the potential for side effects and abuse makes them second-line. (Choice C) Indomethacin is an NSAID medication. There is a theoretical concern that NSAIDs may worsen circulation to the nerves and possibly worsen diabetic neuropathy. Long term use should also be discouraged due to potential adverse renal effects. (Choice D) Corticosteroids such as prednisone are not indicated for painful diabetic neuropathy, and would likely worsen the patient's glycemic control among other possible side effects. (Choice E) Sertraline is an SSRI medication. While tricyclic antidepressants have been shown to improve symptoms of diabetic neuropathy, there is no indication that SSRI medications have a similar effect. Educational objective: Aggressive glycemic control is the most important aspect of treatment for diabetic neuropathy. However, for patients with severe associated pain, treatment with medications like tricyclic antidepressants, duloxetine, or certain anticonvulsant medications (gabapentin, pregabalin) can alter neuronal transmission and decrease pain. While tricyclic antidepressants are effective pain control agents for diabetic neuropathy, SSRIs are not. References: Duloxetine for treating painful neuropathy or chronic pain (http://www.ncbi.nlm.nih.gov/pubmed/19821395)

A 64-Year-Old Woman Comes to the Physician Because She Has