Selecting a medication for diabetic neuropathy can be a bit challenging.  You really need to weigh the adverse effect profile when choosing an agent.  The case: A 55 year old male has a past medical history of diabetes.  He has been experiencing tingling in his feet which hasn’t been too troublesome until lately.  This has recently become more painful, impacting walking and also keeping him up at night.  He has been taking Tylenol PM to try to help get to sleep.

His other relevant diagnosis include; BPH, seasonal allergies, depression, hypertension, and heart failure.

His current medications include; finasteride, tamsulosin, loratadine, sertraline, furosemide, Lisinopril, and metoprolol.

With his new diagnosis of neuropathy comes decisions in trying to treat neuropathy.  There are several options that could be considered reasonable choices.  Here’s a few options to consider.

1. Duloxetine would probably be my first consideration given the past history of depression. Assessment of depression and whether or not we could transition this patient to duloxetine would likely a top consideration.
2. Gabapentin or possibly pregabalin. Both are commonly used for neuropathy.  Gabapentin and pregabalin can exacerbate edema in this patient with CHF, and that fact would make me less likely to select either of these medications. Pregabalin is also still a little while away from going generic which is a big downside.
3. TCA’s could be a viable option. We do have a younger patient, but the diagnosis that would really discourage me from using this class is BPH.  Remember that anticholinergic medications can exacerbate BPH symptoms.  These meds tend to be more sedating which could be an advantage since he is struggling at night.

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