Peripheral Neuropathy Management

Initial Evaluation

The American Diabetes Association recommends assessing for numbness and tingling in hands and/or feet, and characterizing these symptoms in patients with peripheral neuropathy 1, 2
A comprehensive history of the complaint should be obtained, including pain assessment using a simple pain scale, to guide further evaluation and management 1
Evaluate for potential contributing factors, including diabetes mellitus, which is a common cause of peripheral neuropathy 2, 3
The American College of Physicians suggests evaluating for vitamin B12 deficiency, thyroid dysfunction, and chemotherapy history as potential contributing factors to peripheral neuropathy 2, 3

Fasting blood glucose and hemoglobin A1c tests are recommended to assess for diabetes mellitus, a common cause of peripheral neuropathy 2, 3
Hepatitis B, C, and HIV testing should be considered if clinically indicated, as these infections can cause peripheral neuropathy 4
Anti-ganglioside antibodies and anti-MAG antibodies may be tested if Guillain-Barré syndrome or demyelinating neuropathy is suspected, respectively 4, 5

The American Diabetes Association recommends optimizing glucose control in diabetic neuropathy to prevent progression 2, 3
First-line medications for neuropathic pain include pregabalin, duloxetine, and gabapentin, which have been shown to be effective in reducing pain in patients with peripheral neuropathy 2
Regular physical activity, acupuncture, and cognitive behavioral therapy may be recommended as non-pharmacological interventions for neuropathic pain management 1, 6

Annual screening for diabetic neuropathy is recommended for all patients with type 2 diabetes and after 5 years in type 1 diabetes, according to the American Diabetes Association 2, 3
Assess for autonomic neuropathy, such as orthostatic hypotension and gastroparesis, in patients with diabetes 2, 3
Monitor for development of foot ulcers in patients with diabetic neuropathy, as recommended by the American Diabetes Association 7
The National Comprehensive Cancer Network suggests considering duloxetine for neuropathic pain, numbness, and tingling in patients with chemotherapy-induced peripheral neuropathy 1

The American Diabetes Association recommends duloxetine 60 mg once daily as the first-line pharmacological treatment for painful diabetic peripheral neuropathy, with the option to increase to 120 mg daily if needed for additional benefit 8
The American Society of Clinical Oncology suggests that duloxetine is the only agent with appropriate evidence to support its use for established painful chemotherapy-induced peripheral neuropathy, though the benefit is limited 9, 10
Tricyclic antidepressants, such as amitriptyline 25-75 mg/day, are effective for diabetic peripheral neuropathy but have significant anticholinergic side effects 8, 11

The American Diabetes Association recommends optimizing glucose control as the foundational step in managing diabetic peripheral neuropathy to prevent progression, targeting individualized HbA1c goals based on patient factors 8, 11, 12
The American Heart Association suggests addressing hypertension and hyperlipidemia aggressively, as cardiovascular risk factors contribute to diabetic peripheral neuropathy progression 11

Spinal cord stimulation may be considered in extreme cases unresponsive to pharmacotherapy, according to the American Society for Stereotactic and Functional Neurosurgery 8

The American College of Physicians recommends a detailed symptom history and assessment for motor weakness, gait disturbances, and autonomic symptoms, including orthostatic hypotension, to diagnose peripheral neuropathy 13, 14

Physical activity has been demonstrated to improve neuropathic pain and should be offered to all patients, according to the Journal of Clinical Oncology and Ca-A Cancer Journal for Clinicians 13, 14