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Diabetic Neuropathic Pain — FRCA Final MCQ

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EasyPain MedicineDiabetic Neuropathic PainFRCA Final

A 55-year-old man with a 20-year history of type 1 diabetes has symmetrical loss of vibration and position sense in both feet. He also reports burning, shooting pain in both legs that is worse at night and has not responded to paracetamol. He is able and willing to take oral medication. In a non-specialist setting, which pharmacological strategy should be offered as initial treatment for his neuropathic pain?

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Correct answer: C — Start amitriptyline, duloxetine, gabapentin or pregabalin

The correct answer is C. The burning, shooting nocturnal pain with distal sensory loss is typical of painful diabetic peripheral neuropathy. NICE recommends offering a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain other than trigeminal neuralgia. Selection depends on comorbidity, interactions, adverse effects and patient preference, with dose titration and early review. If the first drug is ineffective or not tolerated, NICE recommends switching sequentially to another recommended drug rather than routinely adding combination therapy. NSAIDs do not specifically treat neuropathic pain. Capsaicin cream is an alternative for localised pain when oral treatment is unwanted or cannot be tolerated. Tramadol is reserved for acute rescue therapy, and strong opioids should not routinely be initiated in non-specialist care.

Reference: National Institute for Health and Care Excellence. CG173, Neuropathic pain in adults: pharmacological management in non-specialist settings, recommendations 1.1.8–1.1.12. Last updated 2020. https://www.nice.org.uk/guidance/cg173/chapter/recommendations