Medicines for pain caused by diabetic neuropathy

Medicines used to relieve pain caused by damage to the nerves that supply sensation and touch (peripheral neuropathy) from diabetes may include:

• Duloxetine hydrochloride (Cymbalta), which is an antidepressant. It may cause dry mouth, nausea, constipation, diarrhea, and sometimes dizziness and hot flashes.
• Anticonvulsants such as gabapentin (Neurontin), pregabalin (Lyrica), phenytoin (Dilantin), carbamazepine (Tegretol, Carbatrol), lamotrigine (Lamictal), topiramate (Topamax), and zonisamide (Zonegran).¹ Anticonvulsants are also frequently prescribed to reduce pain associated with diabetic neuropathy.
• Tricyclic antidepressants such as amitriptyline (Elavil, Endep), desipramine (Norpramin, Pertofrane), and imipramine (Tofranil).
• Lidocaine or mexiletine. Lidocaine comes as a patch that you can place on your skin where the pain is the worst. Mexiletine is an oral medicine similar to lidocaine. Both medicines are used to relieve pain caused by neuropathy.
• Capsaicin cream. Capsaicin is a substance contained in cayenne peppers. Although it may not provide complete pain relief, it may help relieve minor pain in some people. Capsaicin cream is applied directly to the skin over the painful area.
• Nonprescription pain relievers. These include acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin), or naproxen sodium (Aleve). Although they may provide some temporary pain relief, they are not effective for long-term treatment of severe pain. Note: People with diabetes need to be especially careful when taking NSAIDs because these medicines may upset kidney function.
• Narcotic pain relievers such as oxycodone, which may reduce moderate to severe pain from diabetic neuropathy.² However, narcotics are usually only given to people who do not have a personal or family history of addiction. Narcotics may also cause side effects that could make symptoms of autonomic neuropathy worse. Therefore, narcotics are not often the first type of medicine tried to reduce symptoms of diabetic neuropathy.

If you begin taking a medicine for pain, it may take several weeks to evaluate whether it is working. The dose may have to be adjusted more than once to find the best balance between pain relief and medicine side effects.

No matter what you or your doctor try, you may not be pain-free. Your doctor may recommend using two or more drugs together to control your pain best. Be clear with your doctor about what is working and what is not. Together you and your doctor can find the best combination of medicine and other treatments to help you the most.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking antidepressants should be watched for warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.
• A warning on anticonvulsants and the risk of suicide and suicidal thoughts. The FDA does not recommend that people stop using these medicines. Instead, people who take anticonvulsant medicine should be watched closely for warning signs of suicide. People who take anticonvulsant medicine and who are worried about this side effect should talk to a doctor.

The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania.

Carbamazepine and lamotrigine may increase the chance of birth defects. If you are pregnant or thinking of getting pregnant, talk to your doctor before taking these medicines.

People of Asian ancestry may be at a higher risk for skin problems from taking carbamazepine. These skin problems, which include Stevens-Johnson syndrome and toxic epidermal necrolysis, can be dangerous. The FDA recommends that people of Asian background be tested before they take carbamazepine.

Citations

1. Pappagallo M (2003). Newer antiepileptic drugs: Possible uses in the treatment of neuropathic pain and migraine. Clinical Therapeutics, 25(10): 2506–2538.

2. Gimbel JS, et al. (2003). Controlled-release oxycodone for pain in diabetic neuropathy: A randomized controlled trial. Neurology, 60(6): 927–934.