Diabetic Neuropathic Pain — RACP Adult Medicine MCQ

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EasyEndocrinologyDiabetic Neuropathic PainRACP Adult Medicine

A 60-year-old woman with diabetic peripheral neuropathy has burning pain in both feet rated 7/10. She has failed paracetamol and topical capsaicin. She has comorbid depression and insomnia. eGFR is 45 mL/min/1.73m². What is the most appropriate first-line neuropathic pain agent?

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Correct answer: D — Duloxetine

Diabetic painful neuropathy with comorbid depression and insomnia — duloxetine (SNRI) is ideal first-line: treats both neuropathic pain AND depression (dual benefit), and is not significantly affected by moderate CKD. NICE and eTG recommend duloxetine, amitriptyline, pregabalin, or gabapentin as first-line for neuropathic pain. Amitriptyline would also be appropriate (helps sleep) but has more anticholinergic side effects in elderly. Pregabalin requires renal dose adjustment (eGFR 45).

Reference: eTG Analgesic – 2024 – Neuropathic Pain; NICE 2024