The Quiz: Diabetic Peripheral Neuropathic Pain

Diabetes mellitus (DM) is a major public health problem. In the US, it affects an estimated 29 million people (9.3% of the population).

Although psychiatrists are usually not called on to treat DM itself, they may frequently see patients with this disease because many suffer comorbid depression. Patients with DM may experience diabetic peripheral neuropathic pain (DPNP); like many types of chronic pain, it is often associated with depression.

As studies have shown that DPNP is often poorly managed, psychiatrists and other mental health professionals may be able to contribute further to the care of their patients with DM by understanding this problem and its proper treatment.

1. Common descriptions of DPNP include which of the following:

A. Burning

B. Electric shocks

C. Stabbing

D. Pins and needles

E. All of the above

2.There is virtually always a direct relationship between the degree of nerve damage that can be measured by nerve conduction studies and the presence and severity of DPNP.

A. True

B. False

3. Most of the studies that have examined gender differences associated with DPNP have found that ___________ are more likely to experience it.

A. Females

B. Males

4. People with DM aged 50 or older are more likely to suffer DPNP than younger patients.

A. True

B. False

5. DPNP is more likely to occur in patients with:

A. Type 1 DM

B. Type 2 DM

C. It is unclear whether DPNP is more likely to occur in patients with one type of DM than it is with the other.

6. It has been shown that poor glycemic control is associated with an increased risk of DPNP.

A. True

B. False

7.The role of psychological factors in the development of DPNP has been clearly demonstrated.

A. True

B. False

8.It has been established that opioid analgesics provide marked analgesia for patients with DPNP.

A. True

B. False

9. Patients with DPNP who use opioids long-term appear at increased risk for which of the following:

A. Depression

B. Opioid addiction

C. Opioid overdose

D. All of the above

10. Which medications are FDA approved for the treatment of DPNP:

A. Duloxetine

B. Pregabalin

C. Tapentadol

D. All of the above

The following questions are based on the Agency for HealthCare Research and Quality (AHRQ) review of diabetic peripheral neuropathy.¹

11. In its review of the literature, the AHRQ found the strongest evidence for the use of which medications for the treatment of DPNP?

A. The anticonvulsants pregabalin and oxcarbazepine

B. The SNRIs duloxetine and venlafaxine

C. The atypical opioids tramadol and tapentadol

D. Injectable neurotoxin botulinum toxin

E. The dietary supplement alpha-lipoic acid

12. There are identifiable predictive factors for determining which medication is most likely to be beneficial for the individual patient with DPNP.

A. True

B. False

13. In addition to being beneficial for the pain related to DPNP, the AHRQ also found that there is evidence indicating that the medications that appear to provide analgesia also improve the level of functioning.

A. True

B. False

14. The AHRQ also found evidence to support the use of which of the following non-pharmacologic therapies for the treatment of DPNP?

A. Exercise and physical therapy

B. Acupuncture

C. Spinal cord stimulation (SCS)

D. Cognitive behavioral therapy (CBT)

E. All of the above

15. The AHRQ review found sufficient evidence to support the use of cannabinoids for the treatment of DPNP.

A. True

B. False

For answers to this quiz, please see the next page.

THE QUIZ/Diabetic Peripheral Neuropathic Pain

1. Answer: E

All of the above. Patients with diabetic neuropathy also commonly complain of numbness, dysesthesia, and trouble with balance.²

2. Answer: B

False. Although patients with more nerve damage are more likely to experience DPNP, there often is no clear correlation between the level of damage and the presence or severity of pain; ie, patients with extensive damage may experience little or no pain, while some with minimal damage may experience marked pain.²

3. Answer: A

Females. Most studies have found that DPNP is more likely to develop in females than in males; however, the number of studies is limited. If there is a gender difference related to DPNP, the reason remains unclear.²

4. Answer: A

True. Older patients appear to be more likely to have DPNP. It is conjectured that the longer a person has DM, the more likely that nerve damage and DPNP will develop.²

5. Answer: C

It is still unclear whether DPNP is more likely to occur in patients with one type of DM than it is with the other. There are limited studies on this issue, and those that have been performed have reported conflicting results.²

6. Answer: A

True. Although people with poor glycemic control are more likely to develop DPNP, it is still unclear whether the poor control is the cause of the DPNP.²

7. Answer: B

False. Although patients with DPNP are more likely to also report depression and anxiety, it is unclear what role these may play in the development of DPNP.²

8. Answer: B

False. Opioids appear to provide limited if any analgesia to patients with most forms of neuropathic pain including DPNP. In fact, findings indicate that patients who take opioid analgesics for extended periods may actually do worse with regard to functioning than those who do not.³

9. Answer: D

All of the above.³ It has been found that patients with DPNP who take opioid analgesics for extended periods are at increased risk for depression, opioid addiction, and opioid overdose. It is therefore important that patients who are treated with opioids be carefully monitored for depression and addiction.

10. Answer: D

All of the above. Although other medications have also been found beneficial for the treatment of DPNP, at the present time only duloxetine, pregabalin, and tapentadol are FDA approved for DPNP treatment.

11. Answer: B

The SNRIs duloxetine and venlafaxine. Although all of the medications in answers A, C, D, and E are more effective for the treatment of DPNP than are placebos, there is a moderate level of supporting evidence for the use of the SNRIs, while there is a low level of supporting evidence for the use of the other medications.

Tramadol and tapentadol are considered atypical opioids because they contain weak opioids combined with an SNRI in the case of tramadol and a norepinephrine reuptake inhibitor in the case of tapentadol. Most of the analgesic effects of these drugs appear to be related to these actions rather than to the opioid.

12. Answer: B

False. The AHRQ reported that there is insufficient research on predictive factors regarding which medication is most likely to be the most effective for the individual patient.

13. Answer: B

False. The AHRQ review found insufficient evidence to determine whether the medications actually improve functioning in addition to providing analgesia.

14. Answer: C

Spinal cord stimulation (SCS). The AHRQ review found a low level of supporting evidence for SCS, although it also noted that this carries the risk of serious complications. With regard to other therapies, the review found that the lack of studies on them made it impossible to comment as of yet on their efficacy.

15. Answer: B

False. Although there is anecdotal support for the use of cannabinoids for DPNP, the AHRQ noted that there was insufficient research to comment on their efficacy.

References:

1. Dy SM, Bennett WL, Sharma R, et al. Preventing Complications and Treating Symptoms of Diabetic Peripheral Neuropathy. Comparative Effectiveness: Review No. 187. AHRQ Publication No. 17-EHC005-ER. Rockville, MD. Agency for Healthcare Research and Quality. March 2017. www.effectivehealthcare.ahrq.gov/ehc/products/612/2436/diabetic-neuropathy-report-170324.pdf. Accessed August 17, 2017.

2. Hebert HL, Veluchamy A, Torrance N, et al. Risk factors for neuropathic pain in diabetes mellitus. Pain. 2017;158:560-568.

3. Hoffman EM, Watson JC, St. Sauver J, et al. Association of long-term opioid therapy with functional status, adverse outcomes, and morality among patients with polyneuropathy. JAMA Neurol. 2017;74:773-779.