Interactive diabetes case 19: Pain and dysesthesias of the lower extremities in a 29-year-old patient with type 1 diabetes (distal sensory neuropathy) – A3

ANSWER — Correct.

A tricyclic antidepressant agent such as nortriptyline is an appropriate first choice for the treatment of painful diabetic neuropathy. While the effectiveness of tricyclic agents in alleviating neuropathic pain is unrelated to the presence of depression, its presence (as in this patient) may be an additional reason to choose an agent in this class.

Nortriptyline and desipramine have less anticholinergic activity than amitriptyline and are the preferred tricyclic medications. These agents are inexpensive. The dose must be adjusted carefully to balance the beneficial effects and the anticholinergic side effects such as dry mouth, urinary retention, constipation, and orthostatic hypotension, the presence of which before treatment are contraindications to their use. The beneficial effects of the tricyclic antidepressants on painful neuropathy may not be apparent for several weeks, so doses should not be increased more rapidly than every two weeks.

The day after you see this woman, you encounter another patient with similar neuropathic symptoms. He is a 69-year-old man with a 13-year history of known type 2 diabetes. At the time of diagnosis of diabetes, he had background diabetic retinopathy and evidence on examination of distal sensory neuropathy. In the interim, he has developed hypertension, microalbuminuria, and benign prostatic hypertrophy, with mild symptoms of bladder outlet obstruction including hesitancy and nocturia.

The metabolic control of his diabetes has never been optimal, with glycated hemoglobin (A1C) values in the range of 7.5 to 8.3 percent on metformin 1000 mg twice a day and glipizide 5 mg every morning. Now he complains of a burning sensation in the soles of his feet that has not responded to aspirin, naproxen, or acetaminophen. The pain prevents him from falling asleep for several hours. He is tired and irritable in the morning and often finds the need to nap in the afternoon.

The dorsal pedal pulses and the posterior tibial pulses are 1+ bilaterally. Neurologic examination reveals decreased vibratory sensation in the great toes and medial malleoli, a lack of sensation to light touch to both calves, absent deep tendon reflexes at the ankles, and reduced deep tendon reflexes at the knees.

What do you recommend for treatment of the patient's pain?

●Nortriptyline 25 mg at bedtime. (See "Interactive diabetes case 19: Pain and dysesthesias of the lower extremities in a 29-year-old patient with type 1 diabetes (distal sensory neuropathy) – B1".)

●Pregabalin 50 mg by mouth three times a day initially, planning to increase to 100 mg three times a day within one week based on tolerability and response. (See "Interactive diabetes case 19: Pain and dysesthesias of the lower extremities in a 29-year-old patient with type 1 diabetes (distal sensory neuropathy) – B2".)

●Duloxetine 60 mg by mouth daily. (See "Interactive diabetes case 19: Pain and dysesthesias of the lower extremities in a 29-year-old patient with type 1 diabetes (distal sensory neuropathy) – B3".)