Painful diabetic peripheral neuropathy (DPN) affects 10—26% of all diabetic patients and continues to pose significant clinical/treatment challenges. Pharmacological treatment of painful DPN includes tricyclic antidepressants (TCAs), selective serotonin noradrenaline reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors, anticonvulsants, opiates, the antioxidant alpha lipoic acid, membrane stabilisers, topical capsaicin etc. Over the past five years many compounds have undergone clinical trials and new agents have immerged. Current first-line therapies for painful DPN are a TCA, SNRI (such as duloxetine) or anticonvulsants (such as pregabalin or gabapentin), taking into account patient co-morbidities and cost. On the basis of cost NICE has recently recommended the use of TCAs before the other first-line agents of painful DPN. Second-line therapies include opiates such as tramadol, morphine and oxycodone.
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