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Neuropathic Pain (Diabetic)

Checked: 22-08-2023 by Vicky Ryan Next Review: 22-08-2025

Overview

There are guidelines on the Management of neuropathic pain in Clinical Knowledge Summaries including diabetic neuropathic pain

Neuropathic pain is a symptom that develops as a result of damage to, or dysfunction of, the somatosensory system.
The pain may be constant or intermittent, and it is typically described as shooting, stabbing, burning, tingling, numb, prickling, or itching.
The causes of neuropathic pain are complex and diverse and include diabetic neuropathy, trigeminal neuralgia, stroke, spinal cord injury, and multiple sclerosis. In many cases, it is not possible to completely cure the underlying disease or lesion or to reverse the neurological changes. Consequently, neuropathic pain is usually persistent in these cases. (1)

Hyperglycaemia contributes to the pathogenesis of neuropathy in both type 1 and type 2 diabetes. Other metabolic and vascular factors, particularly hypertriglyceridaemia, are important.

The clinical presentation comprises a broad constellation of symptoms and deficits, involving sensory, motor, and autonomic nerve fibres, and multiple organ systems.

Diabetic peripheral neuropathy is the most common chronic complication of diabetes, characterised by the presence of peripheral nerve dysfunction, diagnosed after the exclusion of other causes. Pain is the outstanding complaint in most patients, but many patients are completely asymptomatic.(2)

Before Referral

Exclude other causes of pain.

Address risk factors such as poor diabetes control.

Consider drug treatment in primary care using the CKS Management of neuropathic pain guidelines and BNSSG Formulary Chronic Pain Guidelines

If treatment in primary care is not controlling symptoms please see the Persistent (Chronic) pain page for referral criteria and link to CBA policy.

Referral

UHBW

There is a diabetic neuropathy service run by Professor David Wynick, UHBW at Central Health Clinic for patients with moderate to severe diabetic neuropathic pain, resistant to conventional therapies.

It is expected that patients referred to the pain clinic will have tried and failed two or more therapies with appropriate dose-titration, minimising side-effects and thus allowing a therapeutic dose to be achieved.

Please provide details in the referral letter of all analgesic medications tried to date, maximum doses achieved and whether they were discontinued due to lack of efficacy and/or side-effects.

Please refer to the Persistent (Chronic) pain page for further details including links to the Pain clinic proforma and criteria based access policy

Referrals from all primary care GPs will be accepted. The service is on E-Referrals and needs to be booked as Pain management but will be moved to neuropathic pain as required.

Should you have any queries then please contact the Clinic Co-Ordinator on 0117 342 7582

NBT

Please refer to the Persistent (Chronic) pain page for further details including links to the Pain clinic proforma and criteria based access policy.

Spinal Cord Stimulation

NBT also offer Spinal Cord Stimulation (SCS) for the treatment of Painful Diabetic Neuropathy of the lower limbs where criteria are met and exclusions do not apply.

See the Spinal Cord Stimulation Service page for details.

Referrals can be forwarded either directly to Southmead SCS service on the pain form (available in EMIS - please specify for consideration of SCS and state clearly how criteria are met) or through Prof Wynick (UHBW - see above).

Resources

(1) Neuropathic pain - drug treatment | Health topics A to Z | CKS | NICE

(2) Diabetic neuropathy - Symptoms, diagnosis and treatment | BMJ Best Practice

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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