How should I manage a patient with diabetic neuropathy who is experiencing significant pain despite standard treatment?

For a patient with diabetic neuropathy experiencing significant pain despite standard treatment, first ensure a comprehensive clinical review assessing pain severity, impact on daily activities including sleep, psychological wellbeing, and treatment tolerability to guide further management decisions ².

Consider switching or combining pharmacological treatments if initial first-line agents such as amitriptyline, duloxetine, gabapentin, or pregabalin have been ineffective or poorly tolerated, trying alternative agents from this group sequentially ².

Referral to a specialist pain service or a condition-specific service is recommended at any stage if pain is severe, significantly limits lifestyle, or if the underlying condition deteriorates, to access advanced therapies and multidisciplinary input ².

Non-pharmacological approaches such as physical therapies, psychological support, and coping strategies should be integrated alongside pharmacological treatment to optimize pain management and improve quality of life ².

For localized neuropathic pain, topical treatments like capsaicin cream may be considered if oral treatments are unsuitable or not tolerated ².

Tramadol may be used cautiously as short-term rescue therapy but is not recommended for long-term use in non-specialist settings ².

In cases where rapid improvement in glycaemic control has precipitated acute painful neuropathy, reassure the patient that this is usually self-limiting and focus on symptom control until resolution ¹.

Recent literature supports these approaches and highlights the importance of individualized treatment plans, including consideration of newer pharmacological agents and interventional therapies available through specialist services, emphasizing multidisciplinary care to address the complex nature of painful diabetic neuropathy (Staudt et al., 2022; Sloan et al., 2022; Zhang et al., 2024).