Management of Painful Neuropathy
General Measures
- Explanation and reassurance
- Optimise glycaemic control - may require insulin therapy
- Exclude other causes eg alcohol, B12 deficiency
- Foot care education
Stepwise Additive approach
Local Measures
- Foot bed cradle - helps to reduce nocturnal contact discomfort
- Opsite or cling film - helps to reduce contact discomfort
- Capsaicin
Systemic Measures
| Medication | Dose | Side effects/cautions |
| Paracetamol | 1g QDS | |
| NSAID'S eg Ibubrofen | 400mg TDS | GI bleeding, renal impairment |
| Amitriptyline | 10mg nocte then gradually increase to 50 mg/d | Dry mouth
Dizziness Many patients develop side effects on higher doses |
| Tramadol* | 50-100mg TDS-QDS | Drowsiness, confusion |
| Gabapentin This is the most effective agent currently available for the relief of neuropathic pain. | 300mg TDS x3 days, then 400mg TDS x3 days, then 600mg TDS Maximum dose: 800mg TDS. Reduce dose in renal impairment (see BNF) | Dizziness Drowsiness Weight gain |
*Combination of Tramadol 37.5mg and Paracetamol 325mg is not therapeutically effective and is expensive
When to refer to Secondary care
- Disabling pain
- Lack of significant improvement following Amitriptyline therapy
- Foot ulceration
- Autonomic neuropathy
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