The drugs that are approved to reduce the pain of diabetic peripheral neuropathy are expensive. But your doctor can prescribe much less costly drugs that might save you thousands of dollars and may work equally well.
No drugs do anything more than cut the pain. To reverse the neuropathy, you have to act.
A pair of articles that the American College of Physicians published in its November 4 issue of the Annals of Internal Medicine compares our choices and recommends our options. The first of these articles is a review of the "Pharmacologic Interventions for Painful Diabetic Neuropathy" by nine doctors, most of whom work at the Mayo Clinic in Rochester, Minnesota. The second article is an editorial, "Painful Diabetic Neuropathy: Many Similarly Effective Therapies With Widely Dissimilar Costs," by two doctors at the University of Michigan in Ann Arbor.
The review concluded that several different types of drugs can reduce the pain of peripheral neuropathy, but nobody knows which ones work best. The editorial took the analysis one step further: since the prices of these drugs are vastly different, start with those that cost less.
The lead author of the editorial, Brian C. Callaghan, M.D., sent me the full-text of both articles. "Because current evidence does not suggest that the effectiveness of these agents substantively differ," he wrote, "cost considerations should be a prominent part of clinicians’ decision making."
According to drugstore.com, pregabalin (brand name Lyrica) is the most expensive, $2,279.76 per year. Duloxetine (brand name Cymbalta) follows at $2,051.88. Much less expensive alternatives are gablentin, $227.88 per year; amitriptyline, $155.88; and nortriptyline, $239.88. Capsaicin cream, which contains an extract of chili peppers, is also used to treat the pain of diabetic peripheral neuropathy. It is available without prescription for $169.88 per year.
The editorial did not include the cost of a fairly new drug, the long-acting narcotic pain reliever tapentadol ER (brand name Nucynta). You can’t buy it through drugstore.com, but drugs.com quotes prices starting at $4,261.92 per year and going up to $6,953.52 at the highest dose.
Part of the cost problem is that the U.S. Food and Drug Administration has approved only three drugs for diabetic peripheral neuropathy. They are the anticonvulsant pregabalin (Lyrica), the antidepressant duloxetine (Cymbalta and generic versions), and tapentadol ER (Nucynta).
In early 2011 the American Academy of Neurology found strong evidence, a "level A" recommendation, for doctors to prescribe one of these drugs, pregabalin (although this was prior to the FDA’s approval of tapentadol).
But our doctors are allowed to prescribe other drugs for diabetic neuropathy and often do so. That’s because as long as the FDA has approved a drug for one problem, doctors can prescribe it for other problems. The FDA regulates medicine, not doctors. Off-label drug use is both acceptable and common.
If you have diabetes, you have a 50-50 chance of getting peripheral neuropathy. The pain that it causes is the immediate problem, and one of these drugs is likely to make that pain bearable.
For most people, questions of cost are not, of course, the big concern, since their health insurance will foot all of the bill except for a relatively small co-pay. The much bigger question is how you avoid the long-term consequences of untreated peripheral neuropathy.
Untreated neuropathy can cause ulcers that can lead to amputations. Pain medicine won’t prevent this from happening.
You might not feel heat, cold, or pain in your feet or hands. You might not be aware that you have a cut or sore on your foot. Ill-fitting shoes can also cause ulcers. That’s the reason why you need to inspect your feet every day.
No drug can reverse this complication of diabetes. Only bringing your blood sugar down to a normal level and keeping it there can do that.
A normal A1C level is certainly below 6.0. And it’s likely to be much lower yet.
_"_Diabetic neuropathy is caused by high blood sugar," he writes. "It doesn’t happen just because you are diabetic. The reason I don’t have it right now is because I’ve had normal blood sugars, more or less for the past forty years. Prior to that, I had severe neuropathies."
He writes that the neuropathy goes away in two steps. Metabolic neuropathy, where the nerves are swollen with fluid and sorbitol, can go away within weeks. With anatomic neuropathy, where the nerves have actually died, you have to wait until they regenerate. Depending upon the length of the nerve this can take years.
If you just mask the pain with drugs, "the neuropathy will get worse and worse so that eventually your limbs will become totally numb and you won’t be able to feel anything."
If you have diabetic peripheral neuropathy, you will, of course, want to mask the pain. But don’t let that stop you from reversing it.
David Mendosa was a journalist who learned in 1994 that he had type 2 diabetes, which he wrote about exclusively. He died in May 2017 after a short illness unrelated to diabetes. He wrote thousands of diabetes articles, two books about it, created one of the first diabetes websites, and published a monthly newsletter, “Diabetes Update.” His very low-carbohydrate diet, A1C level of 5.3, and BMI of 19.8 kept his diabetes in remission without any drugs until his death.