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Diabetic Peripheral Neuropathy - 4 - Medicines for treatment

Diabetic peripheral neuropathy:Part 4
Medicines for the treatment

The main medicines recommended for neuropathic pain include:
(1)Amitriptyline – also used for treatment of headaches and depression.
(2)Duloxetine – also used for treatment of bladder problems and depression.
(3)Pregabalin and (4)Gabapentin are also used to treat epilepsy, headaches or anxiety.
The treatment for diabetic neuropathy in feet:
According to guidelines from the American Academy of Neurology , the most effective medications for treating painful diabetic neuropathy (PDN) include: Pregabalin (Lyrica) Gabapentin (Neurontin) Duloxetine (Cymbalta)
This medication is commonly prescribed for neuropathy in diabetic patients and are the three most prescribed medications for neuropathy in diabetic patients.

(1) Amitriptyline:
This medication belongs to a class of medications called tricyclic antidepressants. It works by affecting the balance of certain natural chemicals (neurotransmitters such as serotonin) in the brain.
Amitriptyline is a medicine used for treating pain. You can take it to treat nerve pain (neuralgia) and back pain,also to help prevent migraine attacks. Amitriptyline alleviates painful diabetic neuropathy. It is recommended by a variety of guidelines as a first or second line treatment. It is as effective for this indication as Gabapentin or Pregabalin but less well tolerated.Amitriptyline is indicated for the treatment of major depressive disorder and neuropathic pain and for the prevention of migraine and chronic tension headache.
The drug Amitriptyline (also known as Amitriptyline HCl or by the brand names Elavil, Endep, Entrip and Trepiline) is one of a class of drugs that are not primarily sleeping tablets but can be used 'off-label' to treat insomnia. This is because Amitriptyline can have a sedative effect.

The side effects for amitriptyline:
Amitriptyline may cause side effects.The most common side effects are nausea, vomiting, headaches, dry mouth, drowsiness, weakness or tiredness, nightmares, dizziness, constipation, and weight gain. Of note is sexual dysfunction, observed primarily in males. Glaucoma, liver toxicity and abnormal heart rhythms are rare but serious side effects. Blood levels of amitriptyline vary significantly from one person to another, and Amitriptyline interacts with many other medications potentially aggravating its side effects.Elavil has been linked to a condition called QT prolongation, which could cause seizures, fainting, and in fatal cases, death. Research has linked the use of antidepressants to an increased risk of suicidal thoughts and ideation.
Amitriptyline may cause some people to be agitated, irritable, or display other abnormal behaviours. It may also cause some people to have suicidal thoughts and tendencies or to become more depressed. If you or your care giver notice any of these adverse effects, tell your doctor right away.
Amitriptyline is safe to take for a long time. There do not seem to be any lasting harmful effects from taking it for many months or years.
Amitriptyline is not addictive but you can get withdrawal side effects if you stop taking it suddenly.

Amitriptyline don't cause sudden death at lower dose:
SSRI antidepressants and TCAs in doses of less than 100 mg (amitriptyline equivalents) did not increase the risk of sudden cardiac death.
Amitriptyline may cause dementia:
Anticholinergics for depression, such as amitriptyline, dosulepin, and paroxetine, have previously been linked to higher risk of dementia, even when they were used up to 20 years beforehand. Some studies have also suggested that use of any anticholinergic is linked to raised risk of dementia.
Amitriptyline can affect your heart: Amitriptyline may cause a condition that affects the heart rhythm (QT prolongation).
QT prolongation can infrequently result in serious (rarely fatal) fast/irregular heartbeat and other symptoms such as severe dizziness, fainting that need medical attention right away.
Overall, the dose of Amitriptyline ranges from 10 to 75mg daily. The maximal dose of amitriptyline for pain is about 75 mg daily. Anything above 75 mg is probably not effective for pain. Amitriptyline is long-acting, so it only needs to be taken once daily.


Duloxetine is used to treat depression and anxiety. It is also used for pain caused by nerve damage associated with diabetes (diabetic peripheral neuropathy).
The analyses reported here show that duloxetine is efficacious in treating chronic pain as demonstrated by significant improvement in pain intensity, physical functioning and patient
ratings of overall improvement.
The main uses of duloxetine are in major depressive disorder, generalized anxiety disorder, neuropathic pain, chronic musculoskeletal pain, and fibromyalgia. Duloxetine is recommended as a first-line agent for the treatment of chemotherapy induced neuropathy by the American Society of Clinical Oncology.
Weight gain is a possible side effect of Cymbalta (duloxetine). But it can also cause weight loss during the first several months of taking it. Weight gain can happen from taking it for a longer time. You can help manage weight while taking Cymbalta by making healthy lifestyle choices.
Gabapentin is an anticonvulsant that has demonstrated efficacy in PDPN treatment, and duloxetine is a norepinephrine-serotonin reuptake inhibitor also recommended for PDPN(PDPN (Podoplanin) is a Protein Coding gene. Diseases associated with PDPN include Atypical Neurofibroma and Angiosarcoma)and commonly used for major depressive disorder.

The worst side effects of Cymbalta(Duloxetin):
Tell your doctor right away if any of these serious side effects occur: confusion, easy bruising/bleeding, decreased interest in sex, changes in sexual ability, muscle cramps/weakness, shaking (tremor), difficulty urinating, signs of liver problems (such as nausea that doesn't stop, stomach/abdominal pain, vomiting.
Side effects of duloxetine
Difficulty sleeping. Try taking duloxetine first thing in the morning.
Headaches. Make sure you rest and drink plenty of fluids,
Feeling dizzy,Blurred vision,
Feeling or being sick (nausea or vomiting),Dry mouth.

The side effects of duloxetine 30 mg: Nausea, dry mouth, constipation, loss of appetite, tiredness, drowsiness, or increased sweating may occur. If any of these effects last or get worse, tell your doctor promptly. Dizziness or lightheadedness may occur, especially when you first start or increase your dose of this drug.
A Cochrane review concluded that the evidence in support of duloxetine's efficacy in treating painful diabetic neuropathy was adequate and that further trials should focus on comparisons with other medications.
Usual Adult Dose of Duloxetin for Neuropathic Pain:
Initial dose: 30 to 60 mg orally once a day
Maintenance dose: 60 mg orally once a day.

Information compiled by:
Dr. Bhairavsinh Raol