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Indian Journal of Medical Sciences, Vol. 62, No. 7, July, 2008, pp. 291-292 Letter To Editor Prescribing practices for painful diabetic neuropathy Aakash, Sabitha P, Kamath Asha, Adhikari PrabhaM Department of Pharmacology, Kasturba Medical College, Mangalore Code Number: ms08051 Sir, Diabetic neuropathy represents a major health problem worldwide. Along with measures for glycemic control, most patients require pharmacological treatment for painful symptoms. The efficacy of many agents has been confirmed in randomized controlled trials. [1] We administered a questionnaire to the M.D.-qualified general physicians practicing in the locality, inquiring about their prescribing preferences among the drug options that were provided, to treat painful diabetic neuropathy (PDN). Respondents could add to their choice the names of drugs they prescribed but were missing in the questionnaire. This cross-sectional survey, which was approved by the institutional ethics committee, was conducted after obtaining verbal informed consent of the participants. Eighty-nine (out of 90) anonymous questionnaires were returned, and the prescribing preferences were tabulated [Table - 1]. Survey response reflects a lack of majority consensus for a single first-choice drug for symptomatic treatment of PDN. Tricyclic antidepressants (TCAs like amitriptyline, imipramine, doxepin, and nortriptyline), carbamazepine, gabapentin, pregabalin, and duloxetine have undergone clinical trials for use in PDN, but only the latter two are approved by the US FDA for the same. [1],[2] Even though 92% prescribed TCAs, only 40% preferred them as the first-choice drugs. Cardiovascular adverse effects and weight gain associated with TCAs, which can further aggravate the existing problems in diabetic patients, [2] may add to the physicians′ concern to prescribe them initially, despite their low cost. Gabapentin and carbamazepine, the two antiepileptic agents, were the next most frequently prescribed drugs and shared similar ranks even in the order of preference. Carbamazepine, an age-old drug, carries with it the potential to produce serious adverse events; whereas gabapentin is thought to have fewer adverse effects but is expensive. [2] Pregabalin, a newer antiepileptic drug, was rarely (3%) used, probably because of its novelty, cost factor, and potential for serious, although rare, adverse effects. [2] A recent article concludes that TCAs and traditional anticonvulsants are better for short-term pain relief than newer-generation anticonvulsants. [3] Duloxetine is devoid of cardiovascular adverse effects of TCAs and less expensive compared to gabapentin, yet less frequently prescribed (66%) compared to both. Long-term experience with the use of this serotonin-norepinephrine uptake inhibitor is lacking, which may explain its limited use by the study group. Nonsteroidal anti-inflammatory drugs (NSAIDs) figured lower in the preference list, with overall 30% prescribing them. NSAIDs have been used in the treatment of PDN; however, very little research exists about their effectiveness for the same. [2],[4] The role of vitamins B1, B6, and B12 in the treatment of diabetic neuropathy has not been established; therefore, supplementing diet with B vitamins is not recommended as a standard or routine therapeutic option. [5] Significant proportion of survey participants (80%) still prescribed B vitamins for PDN. PDN is associated with increased morbidity and is difficult to treat. Availability of diverse treatment modalities facilitates the physician to tailor the treatment to individual circumstances and provide cost-effective care. It is essential that the physicians stay abreast with the advances in medical therapies available for PDN. References
Copyright 2008 - Indian Journal of Medical Sciences The following images related to this document are available:Photo images[ms08051t1.jpg] |
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