DOCSLIB.ORG

Treating Painful Diabetic Peripheral Neuropathy: an Update MATTHEW J

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

Treating Painful Diabetic Peripheral Neuropathy: An Update MATTHEW J. SNYDER, DO, and LAWRENCE M. GIBBS, MD, Saint Louis University Family Medicine Residency, Belleville, Illinois TAMMY J. LINDSAY, MD, Saint Louis University Family Medicine Residency, St. Louis, Missouri Painful diabetic peripheral neuropathy occurs in approximately 25% of patients with diabetes mellitus who are treated in the office setting and significantly affects quality of life. It typically causes burning pain, paresthesias, and numbness in a stocking-glove pattern that progresses proximally from the feet and hands. Clinicians should carefully consider the patient’s goals and functional status and potential adverse effects of medication when choosing a treat- ment for painful diabetic peripheral neuropathy. Pregabalin and duloxetine are the only medications approved by the U.S. Food and Drug Administration for treating this disorder. Based on current practice guidelines, these medica- tions, with gabapentin and amitriptyline, should be considered for the initial treatment. Second-line therapy includes opioid-like medications (tramadol and tapentadol), venlafaxine, desvenlafaxine, and topical agents (lidocaine patches and capsaicin cream). Isosorbide dinitrate spray and transcutaneous electrical nerve stimulation may provide relief in some patients and can be considered at any point during therapy. Opioids and selective serotonin reuptake inhibitors are optional third-line medications. Acupuncture, traditional Chinese medicine, alpha lipoic acid, acetyl-L-carnitine, primrose oil, and electromagnetic field application lackhigh-quality evidence to support their use. (Am Fam Physi- cian. 2016;94(3):227-234. Copyright © 2016 American Academy of Family Physicians.) CME This clinical content ainful diabetic peripheral neuropa- glucose control in patients with type 1 dia- conforms to AAFP criteria thy (DPN) occurs in approximately betes significantly reduced the risk of devel- for continuing medical education (CME). See 30% of patients with diabetes melli- oping DPN (risk difference = 1.84%; 95% CME Quiz Questions on tus who are hospitalized and in 25% confidence interval [CI], –1.11 to –2.56). page 208. Pof patients with diabetes who are treated in A similar analysis of four RCTs in patients 1 Author disclosure: No rel- the office setting. It develops as a late mani- with type 2 diabetes, however, did not show evant financial affiliations. festation of uncontrolled or long-standing a statistically significant reduction in the ▲ 1 4 Patient information: diabetes. As many as 12% of patients with rate of DPN with enhanced glucose control. A handout on this topic, painful DPN do not report symptoms, and Cardiovascular risk factors, including age, written by the authors of 39% of patients with the disorder do not tobacco use, hypertension, obesity, dyslipid- this article, is available receive any treatment.2 emia, and peripheral artery disease, are also at http://www.aafp.org/ afp/2016/0801/p227-s1. Distal symmetric polyneuropathy, which is associated with an increased risk of painful html. characterized by burning pain, paresthesias, DPN.1 and numbness that follows a stocking-glove Pharmacologic and nonpharmacologic pattern and progresses proximally, occurs interventions are available for the treat- in approximately 26% of patients with DPN. ment of painful DPN. However, there are Less than 20% of patients with diabetes expe- few high-quality, head-to-head clinical tri- rience dynamic mechanical allodynia (pain als comparing these therapeutic approaches, in response to stroking lightly), thermal and because the available studies use varying hyperalgesia (increased sensitivity to pain by methodologies, it is difficult to know which thermal stimuli), or pain attacks. treatment strategy may be most effective. Poorly controlled blood glucose lev- els, especially greater variation in glucose Pharmacologic Treatment Options levels, contribute to the occurrence and Only two medications, pregabalin (Lyr- severity of painful DPN.3 A 2012 Cochrane ica) and duloxetine (Cymbalta), have been review of two randomized controlled tri- approved by the U.S. Food and Drug Admin- als (RCTs; n = 1,228) found that enhanced istration (FDA) for the treatment of DPN. AugustDownloaded 1, 2016 from ◆ the Volume American 94, Family Number Physician 3 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2016 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 227- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Diabetic Peripheral Neuropathy Management of Painful Diabetic Peripheral Neuropathy Initial evaluation Guidelines from national organizations such Rule out other causes of neuropathy* as the American Academy of Neurology, Establish treatment goals Optimize glycemic control however, recommend the use of a broader range of medications. Clinicians should consider the patient’s First-line therapy age, health-related quality-of-life goals, Anticonvulsants Antidepressants (TCAs and SNRIs) physical function, and comorbidities, as well Pregabalin† (Lyrica) Amitriptyline‡ as the possible adverse effects of medication Gabapentin (Neurontin) Duloxetine (Cymbalta) use, in the management of pharmacologic therapy. Additionally, medication dosages and the duration of therapy should be regu- Second-line therapy lated and titrated based on regular patient SNRIs§ Opioid-like drugs Topical treatments feedback regarding pain relief, improved Venlafaxine Tramadol|| Lidocaine 5% patch function, and adverse effects.1 or or or Figure 1 presents a treatment algorithm Desvenlafaxine (Pristiq) Tapentadol ER Capsaisin 0.075% cream (Nucynta ER) for painful DPN based on available evi- dence.1-3,5-8 Selected medications and their dosages, costs, and numbers needed to treat Third-line therapy (NNTs) are presented in Table 1.1,7,9-14 Table 2 SSRIs Opioids¶ lists common adverse effects of medications Citalopram (Celexa) Oxycodone controlled 3,12,13,15 used to treat painful DPN. Common or release 16 drug interactions are described in Table 3. Paroxetine (Paxil) or ANTICONVULSANTS Escitalopram (Lexapro) Anticonvulsants, including topiramate (Topamax), valproate (Depacon), oxcar- May consider adding at any time: bazepine (Trileptal), lamotrigine (Lamic- Isosorbide dinitrate spray (30 mg applied to the bottom of feet before bedtime) tal), and lacosamide (Vimpat), as well as the Transcutaneous electrical nerve stimulation newer calcium channel alpha-2-delta ligand class anticonvulsants (gabapentin [Neuron- ER = extended release; SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant. tin] and pregabalin), have been studied for *—Other causes of neuropathy include malignancy, alcohol use, human immunodefi- the treatment of painful DPN. Based on a ciency virus infection, isoniazid use, and chemotherapy. recent meta-analysis, both the American †—Pregabalin should be used cautiously in patients with heart failure and in persons con- Academy of Neurology and Toronto guide- comitantly using thiazolidinediones, because cases of decompensated heart failure with pregabalin use have been reported.1 In addition, renal insufficiency (creatinine clearance lines recommend pregabalin as the first-line ≤ 30 mL per minute per 1.73 m2 [0.50 mL per second per m2]) requires dose adjustment.3 medication for painful DPN, with gabapen- ‡—Amitriptyline is the only TCA with good evidence of benefit for treating diabetic tin as the first-line alternative.3 neuropathy. TCAs should also be used cautiously and should generally be avoided in older adults because of adverse anticholinergic effects.3,6 TCAs are contraindicated Pregabalin provides consistent pain relief in patients with cardiovascular disease (including unstable angina, recent myocardial based on a dose-dependent response com- infarction, heart failure, and abnormal cardiac conduction) and glaucoma.3 Twelve- pared with placebo. A meta-analysis of seven lead electrocardiography should be performed in all patients older than 40 years to RCTs (n = 1,596) comparing pregabalin with assess for QT prolongation because TCAs may increase the risk of torsades de pointes. §—May consider combination therapy with pregabalin and gabapentin 2,5; however, placebo showed that dosages of 300 mg daily clinicians should be cautious to avoid serotonin syndrome. and 600 mg daily (or divided twice daily) ||—Tramadol lowers the seizure threshold and should be avoided in patients with resulted in greater than 50% pain reduction in epilepsy or in those at risk of seizures.7 ¶—Opioids should be used with caution because long-term use is associated with 39% and 47% of patients, respectively, vs. 22% numerous adverse effects and increased morbidity and mortality. If opioids are used, with placebo. Onset of action occurred at five oxycodone is commonly prescribed, but alternatives include methadone, levorphanol, days with 300 mg and at four days with 600 mg. and morphine. Dosing at 150 mg daily was ineffective.1-3 Common adverse reactions to pregabalin Figure 1. Algorithm for the management of painful diabetic periph- (Table 2 3,12,13,15) produced discontinuation eral neuropathy. rates of 9.8% (300 mg) and 14.6% (600 mg).1 Information from references 1 through 3, and 5 through 8. 228 American Family Physician www.aafp.org/afp Volume 94, Number 3 ◆ August 1, 2016 Diabetic Peripheral Neuropathy
Recommended publications
  • Formulary and Prescribing Guidelines

    Formulary and Prescribing Guidelines

    Formulary and Prescribing Guidelines SECTION 1: TREATMENT OF DEPRESSION Section 1. Treatment of depression 1.1 Introduction This guidance should be considered as part of a stepped care approach in the management of depressive disorders. Antidepressants are not routinely recommended for persistent sub-threshold depressive symptoms or mild depression but can be considered in these categories where there is a past history of moderate or severe depression, initial presentation of sub-threshold depressive symptoms for at least 2 years, and persistence of either mild or sub-threshold depression after other interventions1 have failed. The most current NICE guidance should be consulted wherever possible to obtain the most up to date information. For individuals with moderate or severe depression, a combination of antidepressant medication and a high intensity psychological intervention (CBT or IPT) is recommended. When depression is accompanied by symptoms of anxiety, usually treat the depression first. If the person has an anxiety disorder and co-morbid depression or depressive symptoms, consider treating the anxiety first. Also consider offering advice on sleep hygiene, by way of establishing regular sleep and wake times; avoiding excess eating, avoiding smoking and drinking alcohol before sleep; and taking regular physical exercise if possible. Detailed information on the treatment of depression in children and adolescents can be found in section 12. Further guidance on prescribing for older adults and for antenatal/postnatal service users can be found in section 11 and section 20, respectively. 1.2 Approved Drugs for the treatment of Depression in Adults For licensing indications, see Annex 1 Drug5 Formulation5 Comments2,3,4 Caps 20mg, 60mg Selective serotonin reuptake inhibitor (SSRI) Fluoxetine Liquid 20mg/5ml 1st line SSRI (based on acquisition cost) Tabs 10mg, 25mg, 50mg Amitriptyline Tricyclic (TCA).
  • Diabetic Neuropathy

    Diabetic Neuropathy

    6 Diabetic Neuropathy Solomon Tesfaye, MD, FRCP INTRODUCTION Polyneuropathy is one of the commonest complications of the diabetes and the com- monest form of neuropathy in the developed world. Diabetic polyneuropathy encompasses several neuropathic syndromes, the most common of which is distal symmetrical neuropa- thy, the main initiating factor for foot ulceration. The epidemiology of diabetic neuropathy has recently been reviewed in reasonable detail (1). Several clinic- (2,3) and population- based studies (4,5) show surprisingly similar prevalence rates for distal symmetrical neu- ropathy, affecting about 30% of all people with diabetes. The EURODIAB prospective complications study, which involved the examination of 3250 patient with type 1 from 16 European countries, found a prevalence rate of 28% for distal symmetrical neuropathy (2). After excluding those with neuropathy at baseline, the study showed that over a 7-year period, about one-quarter of patients with type 1 diabetes developed distal symmetrical neuropathy; age, duration of diabetes, and poor glycemic control being major determinants (6). The development of neuropathy was also associated with potentially modifiable car- diovascular risk factors such as serum lipids, hypertension, body mass index, and cigaret smoking (6). Furthermore, cardiovascular disease at baseline carried a twofold risk of neu- ropathy, independent of cardiovascular risk factors (6). Based on recent epidemiological studies, correlates of diabetic neuropathy include increasing age, increasing duration of dia- betes, poor glycemic control, retinopathy, albuminuria, and vascular risk factors (1,2,4,6). The differing clinical presentation of the several neuropathic syndromes in diabetes sug- gests varied etiological factors. CLASSIFICATION Clinical classification of the various syndromes of diabetic peripheral neuropathy has proved difficult.
  • Diabetic Peripheral Neuropathy

    Diabetic Peripheral Neuropathy

    PHYSICIAN REFERRAL DIABETIC PATIENT’S NAME: PERIPHERAL _________________________________ _________________________________ NEUROPATHY DIAGNOSIS: _________________________________ _________________________________ PRECAUTIONS: BACCI & GLINN _________________________________ PHYSICAL THERAPY, INC. _________________________________ For more information on this and _____ Evaluate and Treat other topics, visit our website at: “Therapy with a Difference” _____ Exercise Program (i.e. home, gym) www.bandgpt.com _____ Functional Conditioning _____ Therapeutic Exercise _____ Balance Training _____ Aquatic Therapy (Hanford only) BACCI & GLINN _____ Modalities PHYSICAL THERAPY, INC. _____ Other ______________________ COMMENTS: _____________________ 5533 West Hillsdale Avenue, Suite A Visalia, CA 93291 ________________________________ Phone: 559-733-2478 Frequency: ___ x per week for ___ weeks Fax: 559-733-2470 Signature: _________________________ 331 North 11th Avenue (Physician signature) Hanford, CA 93230 Date: __________ Phone: 559-582-1027 Fax: 559-582-8105 SAME DAY APPOINTMENTS AVAILABLE Referrals are accepted from any physician. A physician’s order and diagnosis are required for evaluation and treatment. We accept most insurances including Medicare. Johnson Designs Bacci & Glinn Physical Therapy, Inc. Hanford: 559-582-1027 Visalia: 559-733-2478 Diabetic Peripheral Neuropathy What is Diabetic Signs and Symptoms of Treatment Options Peripheral Neuropathy? Diabetic Peripheral Neuropathy There is no cure for diabetic neuropa- Diabetic neuropathy is a nerve ♦ Tingling, tightness, or burning, shooting thy. Treatment focuses on slowing the disorder commonly caused by or stabbing pain in feet, hands, or other progression of the disease. Your diabetes. High blood sugar levels parts of the body. physician will determine the best from diabetes can damage nerves ♦ Reduced feeling or numbness, most treatment for your peripheral neuropa- throughout the body. About 50% of often in the feet.
  • Diabetic Neuropathy

    Diabetic Neuropathy

    PRIMER Diabetic neuropathy Eva L. Feldman1*, Brian C. Callaghan1, Rodica Pop-Busui2, Douglas W. Zochodne3, Douglas E. Wright4, David L. Bennett5, Vera Bril6,7, James W. Russell8 and Vijay Viswanathan9 Abstract | The global epidemic of prediabetes and diabetes has led to a corresponding epidemic of complications of these disorders. The most prevalent complication is neuropathy , of which distal symmetric polyneuropathy (for the purpose of this Primer, referred to as diabetic neuropathy) is very common. Diabetic neuropathy is a loss of sensory function beginning distally in the lower extremities that is also characterized by pain and substantial morbidity. Over time, at least 50% of individuals with diabetes develop diabetic neuropathy. Glucose control effectively halts the progression of diabetic neuropathy in patients with type 1 diabetes mellitus, but the effects are more modest in those with type 2 diabetes mellitus. These findings have led to new efforts to understand the aetiology of diabetic neuropathy , along with new 2017 recommendations on approaches to prevent and treat this disorder that are specific for each type of diabetes. In parallel, new guidelines for the treatment of painful diabetic neuropathy using distinct classes of drugs, with an emphasis on avoiding opioid use, have been issued. Although our understanding of the complexities of diabetic neuropathy has substantially evolved over the past decade, the distinct mechanisms underlying neuropathy in type 1 and type 2 diabetes remains unknown. Future discoveries on disease pathogenesis will be crucial to successfully address all aspects of diabetic neuropathy , from prevention to treatment. The International Diabetes Federation estimates that neuropathies secondary to diabetes can occur (Fig.
  • Diabetic Neuropathy: a Position Statement by the American

    Diabetic Neuropathy: a Position Statement by the American

    136 Diabetes Care Volume 40, January 2017 Diabetic Neuropathy: A Position Rodica Pop-Busui,1 Andrew J.M. Boulton,2 Eva L. Feldman,3 Vera Bril,4 Roy Freeman,5 Statement by the American Rayaz A. Malik,6 Jay M. Sosenko,7 and Dan Ziegler8 Diabetes Association Diabetes Care 2017;40:136–154 | DOI: 10.2337/dc16-2042 Diabetic neuropathies are the most prevalent chronic complications of diabetes. This heterogeneous group of conditions affects different parts of the nervous system and presents with diverse clinical manifestations. The early recognition and appropriate man- agement of neuropathy in the patient with diabetes is important for a number of reasons: 1. Diabetic neuropathy is a diagnosis of exclusion. Nondiabetic neuropathies may be present in patients with diabetes and may be treatable by specific measures. 2. A number of treatment options exist for symptomatic diabetic neuropathy. 3. Up to 50% of diabetic peripheral neuropathies may be asymptomatic. If not recognized and if preventive foot care is not implemented, patients are at risk for injuries to their insensate feet. 4. Recognition and treatment of autonomic neuropathy may improve symptoms, POSITION STATEMENT reduce sequelae, and improve quality of life. Among the various forms of diabetic neuropathy, distal symmetric polyneurop- athy (DSPN) and diabetic autonomic neuropathies, particularly cardiovascular au- tonomic neuropathy (CAN), are by far the most studied (1–4). There are several 1 atypical forms of diabetic neuropathy as well (1–4). Patients with prediabetes may Division of Metabolism, Endocrinology & Diabe- – tes, Department of Internal Medicine, University also develop neuropathies that are similar to diabetic neuropathies (5 10).
  • Nerve Pain in Diabetes

    Nerve Pain in Diabetes

    Information O from Your Family Doctor Nerve Pain in Diabetes What is nerve pain in diabetes? feeling in your feet and it affects your balance, Nerve pain with diabetes is called neuropathy there are special shoes that can help. (new-ROP-uh-thee). It is common in people with uncontrolled diabetes. It usually starts in What can I expect? the feet and may go up the legs. It may cause Medicine will lessen the pain for many patients, burning pain or a loss of feeling. but most will still have some pain. It is also important to wear proper fitting shoes. And, What causes it? every time you see the doctor, have the doctor Nerves are like wires that bring feeling to your check your feet for injuries you cannot feel. brain from other parts of the body. High blood sugar levels can damage those nerves. The Where can I get more information? longer you have high blood sugar, the more Your doctor likely you are to get nerve damage. The nerves AAFP’s Patient Education Resource in your feet are usually the first to be damaged. http://familydoctor.org/familydoctor/en/diseases- Nerves in other parts of the body can be conditions/diabetic-neuropathy.html damaged, too. American Diabetes Association http://www.diabetes.org/living-with-diabetes/ How do I know if I have it? complications/neuropathy/peripheral-neuropathy.html If you have nerve damage in your feet, you will National Institutes of Health and National Institute of notice pain or loss of feeling. Your doctor can Diabetes and Digestive and Kidney Diseases do tests to be sure that is what is causing the http://www.niddk.nih.gov/health-information/health- problem.
  • Duloxetine for Chronic Pain Relief

    Duloxetine for Chronic Pain Relief

    Patient Information Leaflet Duloxetine for Chronic Pain Relief Produced By: Chronic Pain Service April 2014 Review due April 2017 1 If you require this leaflet in another language, large print or another format, please contact the Quality Team, telephone 01983 534850, who will advise you. Duloxetine ( Cymbalta ) is a medicine used to relieve chronic pain and treat low mood. It is often helpful for nerve-related pain or pain sensitivity (also called central sensitisation ). It has a different way of relieving pain than standard pain killers and is often prescribed in combination. If used for pain other than diabetes-related neuropathic pain it is formally used outside it’s product license as per individual decision by your pain specialist/doctor. As it affects the central nervous system in complex ways, the effect often takes a while to be felt and requires regular intake . We recommend a trial of at least four weeks to judge the effect. If good, it should be taken on a regular long-term basis; if there is no distinct relief it should be discontinued after the trial period. If you suffer with seizures/epilepsy, glaucoma and poorly controlled high blood pressure, Duloxetine should be used with caution and at a lower dose (up to 60mg per day). The most common side effect is drowsiness/dizziness therefore it is best time to take it in the evening. There are many other possible side effects, but most are uncommon, rare or very rare (please take a look at the product leaflet) We suggest that you avoid driving for at least 2 days after starting or increasing the dose of this medication.
  • Milnacipran for Pain in Fibromyalgia in Adults

    Milnacipran for Pain in Fibromyalgia in Adults

    Milnacipran for pain in fibromyalgia in adults (Review) Cording M, Derry S, Phillips T, Moore RA, Wiffen PJ This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2015, Issue 10 http://www.thecochranelibrary.com Milnacipran for pain in fibromyalgia in adults (Review) Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 6 OBJECTIVES ..................................... 7 METHODS ...................................... 7 RESULTS....................................... 9 Figure1. ..................................... 10 Figure2. ..................................... 12 Figure3. ..................................... 13 Figure4. ..................................... 14 Figure5. ..................................... 18 DISCUSSION ..................................... 21 AUTHORS’CONCLUSIONS . 22 ACKNOWLEDGEMENTS . 23 REFERENCES ..................................... 23 CHARACTERISTICSOFSTUDIES . 27 DATAANDANALYSES. 38 Analysis 1.1. Comparison 1 Milnacipran 100 mg/day versus placebo, Outcome 1 At least 30% pain relief. 39 Analysis 1.2. Comparison 1 Milnacipran 100 mg/day versus placebo, Outcome 2 PGIC ’much improved’ or ’very much improved’.................................... 40 Analysis 1.3. Comparison
  • Adverse Effects of First-Line Pharmacologic Treatments of Major Depression in Older Adults

    Adverse Effects of First-Line Pharmacologic Treatments of Major Depression in Older Adults

    Draft Comparative Effectiveness Review Number xx Adverse Effects of First-line Pharmacologic Treatments of Major Depression in Older Adults Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov This information is distributed solely for the purposes of predissemination peer review. It has not been formally disseminated by the Agency for Healthcare Research and Quality. The findings are subject to change based on the literature identified in the interim and peer-review/public comments and should not be referenced as definitive. It does not represent and should not be construed to represent an Agency for Healthcare Research and Quality or Department of Health and Human Services (AHRQ) determination or policy. Contract No. 290-2015-00012I Prepared by: Will be included in the final report Investigators: Will be included in the final report AHRQ Publication No. xx-EHCxxx <Month, Year> ii Purpose of the Review To assess adverse events of first-line antidepressants in the treatment of major depressive disorder in adults 65 years or older. Key Messages • Acute treatment (<12 weeks) with o Serotonin norepinephrine reuptake inhibitors (SNRIs) (duloxetine, venlafaxine), but not selective serotonin reuptake inhibitors (SSRIs) (escitalopram, fluoxetine) led to a greater number of adverse events compared with placebo. o SSRIs (citalopram, escitalopram and fluoxetine) and SNRIs (duloxetine and venlafaxine) led to a greater number of patients withdrawing from studies due to adverse events compared with placebo o Details of the contributing adverse events in RCTs were rarely reported to more clearly characterize what adverse events to expect.
  • Cymbalta (Duloxetine Hcl) Prior Authorization of Benefits Form

    Cymbalta (Duloxetine Hcl) Prior Authorization of Benefits Form

    Cymbalta (Duloxetine HCl) Prior Authorization of Benefits Form CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to: Prior Authorization of Benefits Center at 844-512-9005 for retail pharmacy or 844-512-7027 for medical injectable. 1. Patient information 2. Physician information Patient name: _________________________________ Prescribing physician: _______________________________ Patient ID #: __________________________________ Physician address: _________________________________ Patient DOB: _________________________________ Physician phone #: _________________________________ Date of Rx: ___________________________________ Physician fax #: ____________________________________ Patient phone #: _______________________________ Physician specialty: _________________________________ Patient email address: __________________________ Physician DEA: ____________________________________ Physician NPI #: ___________________________________ Physician email address: ____________________________ 3. Medication 4. Strength 5. Directions 6. Quantity per 30 days Cymbalta (Duloxetine HCl) ______________________ _____________________ Specify: ________________________ 7. Diagnosis: ____________________________________________________________________________________ 8. Approval criteria: (Check all boxes that apply. Note: Any areas not filled out are considered not applicable to your patient and may affect the outcome of this request.) Major depressive disorder (MDD), depressive disorder or dysthymia: □ Yes □ No Patient has
  • Medication Guide Duloxetine Delayed-Release Capsules, USP (Doo-LOX

    Medication Guide Duloxetine Delayed-Release Capsules, USP (Doo-LOX

    Medication Guide Duloxetine Delayed-Release Capsules, USP (doo-LOX-e-teen) Read this Medication Guide before you start taking duloxetine delayed-release capsules and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or treatment. Talk to your healthcare provider about: • all risks and benefits of treatment with antidepressant medicines • all treatment choices for depression or other serious mental illness What is the most important information I should know about antidepressant medicines, depression, other serious mental illnesses, and suicidal thoughts or actions? 1. Duloxetine delayed-release capsules and other antidepressant medicines may increase suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed. 2. Depression and other serious mental illnesses are the most important causes of suicidal thoughts or actions. Some people may have a particularly high risk of having suicidal thoughts or actions. These include people who have (or have a family history of) bipolar illness (also called manic-depressive illness). 3. How can I watch for and try to prevent suicidal thoughts and actions? • Pay close attention to any changes in mood, behavior, actions, thoughts, or feelings, especially sudden changes. This is very important when an antidepressant medicine is started or when the dose is changed. • Call your healthcare provider right away to report new or sudden changes in mood, behavior, thoughts, or feelings. • Keep all follow-up visits with your healthcare provider as scheduled.
  • Diabetic Neuropathies: the Nerve Damage of Diabetes

    Diabetic Neuropathies: the Nerve Damage of Diabetes

    Diabetic Neuropathies: The Nerve Damage of Diabetes National Diabetes Information Clearinghouse What are diabetic • neurovascular factors, leading to dam­ age to the blood vessels that carry neuropathies? oxygen and nutrients to nerves Diabetic neuropathies are a family of nerve • autoimmune factors that cause inflam­ disorders caused by diabetes. People with U.S. Department mation in nerves of Health and diabetes can, over time, develop nerve dam­ Human Services age throughout the body. Some people with • mechanical injury to nerves, such as nerve damage have no symptoms. Others carpal tunnel syndrome NATIONAL may have symptoms such as pain, tingling, INSTITUTES • inherited traits that increase susceptibil­ OF HEALTH or numbness—loss of feeling—in the hands, ity to nerve disease arms, feet, and legs. Nerve problems can • lifestyle factors, such as smoking or occur in every organ system, including the alcohol use digestive tract, heart, and sex organs. About 60 to 70 percent of people with diabe­ What are the symptoms of tes have some form of neuropathy. People with diabetes can develop nerve problems at diabetic neuropathies? any time, but risk rises with age and longer Symptoms depend on the type of neuropathy duration of diabetes. The highest rates of and which nerves are affected. Some people neuropathy are among people who have with nerve damage have no symptoms at all. had diabetes for at least 25 years. Diabetic For others, the first symptom is often numb­ neuropathies also appear to be more com­ ness, tingling, or pain in the feet. Symptoms mon in people who have problems control­ are often minor at first, and because most ling their blood glucose, also called blood nerve damage occurs over several years, sugar, as well as those with high levels of mild cases may go unnoticed for a long time.