Clinician Article
Pharmacologic interventions for painful diabetic neuropathy: An umbrella systematic review and comparative effectiveness network meta-analysis.
PMID: 25364885
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Family Medicine (FM)/General Practice (GP)Relevance - 6/7
Newsworthiness - 6/7 -
General Internal Medicine-Primary Care(US)Relevance - 6/7
Newsworthiness - 6/7 -
Internal MedicineRelevance - 6/7
Newsworthiness - 6/7 -
EndocrineRelevance - 6/7
Newsworthiness - 5/7 -
NeurologyRelevance - 6/7
Newsworthiness - 4/7 -
Special Interest - Pain -- PhysicianRelevance - 5/7
Newsworthiness - 4/7
Abstract
BACKGROUND: Multiple treatments for painful diabetic peripheral neuropathy are available.
PURPOSE: To evaluate the comparative effectiveness of oral and topical analgesics for diabetic neuropathy.
DATA SOURCES: Multiple electronic databases between January 2007 and April 2014, without language restriction.
STUDY SELECTION: Parallel or crossover randomized, controlled trials that evaluated pharmacologic treatments for adults with painful diabetic peripheral neuropathy.
DATA EXTRACTION: Duplicate extraction of study data and assessment of risk of bias.
DATA SYNTHESIS: 65 randomized, controlled trials involving 12 632 patients evaluated 27 pharmacologic interventions. Approximately one half of these studies had high or unclear risk of bias. Nine head-to-head trials showed greater pain reduction associated with serotonin-norepinephrine reuptake inhibitors (SNRIs) than anticonvulsants (standardized mean difference [SMD], -0.34 [95% credible interval {CrI}, -0.63 to -0.05]) and with tricyclic antidepressants (TCAs) than topical capsaicin 0.075%. Network meta-analysis showed that SNRIs (SMD, -1.36 [CrI, -1.77 to -0.95]), topical capsaicin (SMD, -0.91 [CrI, -1.18 to -0.08]), TCAs (SMD, -0.78 [CrI, -1.24 to -0.33]), and anticonvulsants (SMD, -0.67 [CrI, -0.97 to -0.37]) were better than placebo for short-term pain control. Specifically, carbamazepine (SMD, -1.57 [CrI, -2.83 to -0.31]), venlafaxine (SMD, -1.53 [CrI, -2.41 to -0.65]), duloxetine (SMD, -1.33 [CrI, -1.82 to -0.86]), and amitriptyline (SMD, -0.72 [CrI, -1.35 to -0.08]) were more effective than placebo. Adverse effects included somnolence and dizziness with TCAs, SNRIs, and anticonvulsants; xerostomia with TCAs; and peripheral edema and burning sensation with pregabalin and capsaicin.
LIMITATION: Confidence in findings was limited because most evidence came from indirect comparisons of trials with short (=3 months) follow-up and unclear or high risk of bias.
CONCLUSION: Several medications may be effective for short-term management of painful diabetic neuropathy, although their comparative effectiveness is unclear.
PRIMARY FUNDING SOURCE: Mayo Foundation for Medical Education and Research.
Clinical Comments
Endocrine
An interesting review that looks at the effectiveness of various pharmacological agents in alleviating pain in polyneuropathy. The findings were relevant to short term treatment but failed to show strong evidence in support of any of the agents reviewed. It appears that the serotonin-norepinephrine re-uptake inhibitors are the most effective group of agents studied.
Family Medicine (FM)/General Practice (GP)
While limited by lack of direct comparison, this article provides some evidence of the effectiveness of short and long term treatments of diabetic neuropathy.
Internal Medicine
Well done systematic review, despite a lot of studies, there are a limited number of head to head comparisons. The results fit with the general clinical experience with the various drug classes.
Neurology
Diabetic neuropathy adversely affects the quality of life, and does not seem to respond to control of blood sugar. This research study is not of much help to practitioners because there is no head-to-head comparison results.
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