The American Academy of Neurology has published an evidence-based guideline on the treatment of painful diabetic neuropathy (PDN).  The guideline was established through a systematic review of the published literature (1960 to August 2008) reporting on the efficacy of various pharmacological treatments, including anticonvulsants, antidepressants, and opioids, as well as non-pharmacological treatments (e.g. electrical stimulation, magnetic field treatment, low-intensity laser treatment, and Reiki massage). The guideline authors rate the various therapeutic options based on the quality of the supporting evidence. 

The main recommendations made with respect to pharmacological therapies are as follows:

Anticonvulsants

• If clinically appropriate, pregabalin should be offered for the treatment of PDN (Level A).

• Gabapentin and sodium valproate should be considered for the treatment of PDN (Level B).

• There is insufficient evidence to support or refute the use of topiramate for the treatment of PDN (Level U).

• Oxcarbazepine, lamotrigine, and lacosamide should probably not be considered for the treatment of PDN (Level B).

Antidepressants

• Amitriptyline, venlafaxine, and duloxetine should be considered for the treatment of PDN (Level B). Data are insufficient to recommend one of these agents over the others.

• Venlafaxine may be added to gabapentin for a better response (Level C).

• There is insufficient evidence to support or refute the use of desipramine, imipramine, fluoxetine, or the combination of nortriptyline and fluphenazine in the treatment of PDN (Level U).

Opioids

• Dextromethorphan, morphine sulphate, tramadol, and oxycodone should be considered for the treatment of PDN (Level B). Data are insufficient to recommend one agent over the other.

Other agents

• Capsaicin and isosorbide dinitrate spray should be considered for the treatment of PDN (Level B).

• Clonidine, pentoxifylline, and mexiletine should probably not be considered for the treatment of PDN (Level B).

• The Lidoderm patch may be considered for the treatment of PDN (Level C).

• There is insufficient evidence to support or refute the usefulness of vitamins and [alpha]-lipoic acid in the treatment of PDN (Level U).