Pharmacologic treatment options for peripheral diabetic neuropathy

Table 6.2-1. Pharmacologic treatment options for peripheral diabetic neuropathy
Agent	Starting dose	Maximum dose	Adverse effects
Antidepressants
Amitriptyline (TCA)	10-25 mg PO at bedtime	150 mg/d	Anticholinergic effects, QT prolongation, urinary retention
Duloxetine (SNRI)	30 mg PO daily	120 mg/d	Nausea, constipation, lethargy, ataxia, sexual dysfunction
Venlafaxine (SNRI)	37.5 mg PO daily	225 mg/d	Nausea, vertigo, lethargy, hyperhidrosis, sexual dysfunction, hypertension
Gabapentinoids
Gabapentin	600 mg PO tid	3600 mg/d	Lethargy, vertigo, peripheral edema
Pregabalin	150 mg PO bid	600 mg/d	Lethargy, vertigo, peripheral edema
Opioids
Tramadol	50 mg qid	400 mg/d	Nausea, vomiting, constipation, lethargy, seizures, ataxia
Tapentadol	100 mg PO bid	250 mg PO bid	Nausea, vomiting, constipation, lethargy, seizures, ataxia
Morphine SR	15 mg bid	180 mg/d	Nausea, vomiting, constipation, dizziness, respiratory depression
Oxycodone ER	10 mg bid	160 mg/d
Topical
Nitrate	30-mg spray at bedtime	60 mg/d	Hypotension, interaction with PDE-5 inhibitors
Capsaicin cream 0.075%	Apply tid to qid	5-6 times/d	Pain, erythema, itching
Other
Alpha-lipoic acid	600 mg PO daily	1800 mg PO daily	Nausea
Carbamazepine	200 mg PO daily	1200 mg/d	Nausea, vomiting, dizziness, ataxia
Adapted from Can J Diabetes. 2018;42:S88-S103 and Int J Immunopathol Pharmacol. 2019 Jan-Dec;33:2058738419838383.
bid, 2 times a day; PDE-5, phosphodiesterase 5; PO, oral; qid, 4 times a day; SNRI, serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant; tid, 3 times a day.