Current and emerging treatments for the diabetic neuropathies

This review focuses on the therapeutic approach to patients with symptomati c diabetic neuropathies, Diabetic neuropathy is a diagnosis that requires e xclusion of other causes; there are no diagnostic tests that confirm that t he symptoms and signs are definitely a result of diabetes. For those patien ts with painful or paresthetic symptoms, optimal stable glycemic control sh ould be the first aim, remembering that insulin is not always required in t ype 2 diabetes. The tricyclic drugs, usually amitriptyline or imipramine, r emain the first-line drug therapy for painful symptoms. Their efficacy has been confirmed in several controlled trials, Of the newer agents, the antic onvulsant gabapentin seems to offer many of the benefits of the tricyclic a gents without the troublesome side effects, and the centrally acting drug t ramadol has proven efficacy for short-term treatment. Topical or nonpharmac ologic treatments may help in some cases; some data support the use of topi cal capsaicin, and longterm open trials suggest a possible benefit of acupu ncture. Of new agents that may modify pathogenetic mechanisms leading to ne uropathy, the antioxidant or-lipoic acid shows promise from a number of con trolled studies. The results of multinational multicenter trials of this ag ent and newer, potent aldose reductase inhibitors are awaited with interest . Recent developments in autonomic neuropathy include the arrival of silden afil, which appears to help up to 60% of patients with erectile dysfunction , Topical glycopyrrolate is another new therapy for autonomic dysfunction; in a randomized trial, it was confirmed to markedly reduce gustatory sweati ng, Finally, whereas <20% of neuropathic patients experience symptoms, ail neuropathic patients are at potential risk of insensitive foot ulceration a nd require education in preventive foot care, regular podiatry, and frequen t followup, always inspecting the feet.