1、 2011 AMERICAN ACADEMY OF NEUROLOGY Treatment of Painful Diabetic Neuropathy Report of the American Academy of Neurology,the American Association of Neuromuscular and Electrodiagnostic Medicine,and the American Academy of Physical Medicine and Rehabilitation Vera Bril,MD,FRCP(C);John England,MD,FAAN
2、;Gary M.Franklin,MD,MPH,FAAN;Miroslav Backonja,MD;Jeffrey Cohen,MD,FAAN;David Del Toro,MD;Eva Feldman,MD,PhD,FAAN;Donald J.Iverson,MD,FAAN;Bruce Perkins,MD,FRCP(C),MPH;James W.Russell,MD,MS,FRPC;Douglas Zochodne,MD 2011 AMERICAN ACADEMY OF NEUROLOGY If you have questions,comments,or feedback regardi
3、ng this slide presentation,or would like to modify the contents for presentation in a lecture,please contact guidelinesaan 2011 AMERICAN ACADEMY OF NEUROLOGY Presentation Objectives To present analysis of the efficacy of pharmacologic and nonpharmacologic treatments to reduce pain and improve physic
4、al function and quality of life(QOL)in patients with painful diabetic neuropathy(PDN)To present evidence-based recommendations 2011 AMERICAN ACADEMY OF NEUROLOGY Overview Background Gaps in care American Academy of Neurology(AAN)guideline process Analysis of evidence,conclusions,recommendations Reco
5、mmendations for future research 2011 AMERICAN ACADEMY OF NEUROLOGY Background Diabetic sensorimotor polyneuropathy represents a diffuse symmetric and length-dependent injury to peripheral nerves that has major implications for QOL,morbidity,and cost from a public health perspective.1,2 PDN affects 1
6、6%of patients with diabetes;it is frequently unreported(12.5%)and more frequently untreated(39%).3 PDN presents an ongoing management problem for patients,caregivers,and physicians.Many treatment options are available,and a rational approach to treating patients with PDN requires an understanding of
7、 the evidence for each intervention.This guideline addresses the efficacy of pharmacologic and nonpharmacologic treatments to reduce pain and improve physical function and QOL in patients with PDN.2011 AMERICAN ACADEMY OF NEUROLOGY Background,cont.Pharmacologic Agents:Anticonvulsants,antidepressants
8、,opioids,antiarrhythmics,cannabinoids,aldose reductase inhibitors,protein kinase C beta inhibitors,antioxidants(-lipoic acid),transketolase activators(thiamines and allithiamines),topical medications(analgesic patches,anesthetic patches,capsaicin cream,clonidine),and others Nonpharmacologic Modaliti
9、es:Infrared therapy,shoe magnets,exercise,acupuncture,external stimulation(transcutaneous electrical nerve stimulation),spinal cord stimulation,biofeedback and behavioral therapy,surgical decompression,and intrathecal baclofen 2011 AMERICAN ACADEMY OF NEUROLOGY Gaps in Care The chronic effect of dru
10、g therapies is not known(how long to treat,when or whether to withdraw treatment).There is an insufficient number of comparative studies among high-quality studies(most were Class II or lower).There is no uniformity in how to measure pain,QOL,and function across the studies examined.Lack of cost eff
11、ectiveness is apparent in all of the studies.Estimated numbers needed to treat are available,but numbers needed to harm are not available.The AAN classifies studies by quality of the evidence,not by cost.2011 AMERICAN ACADEMY OF NEUROLOGY Gaps in Care,cont.Practitioners dont identify pain enough in
12、peripheral neuropathy or diabetic neuropathy.Patients with diabetes often arent aware that nerve pain is a symptom.Most neuropathy therapies treat pain but not numbness.There is a lack of attention to PDN as a disease entity.2011 AMERICAN ACADEMY OF NEUROLOGY AAN Guideline Process Clinical Question
13、Evidence Conclusions Recommendations 2011 AMERICAN ACADEMY OF NEUROLOGY Clinical Questions The first step in developing guidelines is to clearly formulate questions to be answered.Questions address areas of controversy,confusion,or variation in practice.Questions must be answerable with data from th
14、e literature.Answering the question must have the potential to improve care/patient outcomes.2011 AMERICAN ACADEMY OF NEUROLOGY Literature Search/Review Relevant Complete Search Review abstracts Review full text Select articles Rigorous,Comprehensive,Transparent 2011 AMERICAN ACADEMY OF NEUROLOGY AA
15、N Classification of Evidence All studies rated Class I,II,III,or IV Five different classification systems:Therapeutic Randomization,control,blinding Diagnostic Comparison to gold standard Prognostic Screening Causation 2011 AMERICAN ACADEMY OF NEUROLOGY AAN Level of Recommendations A=Established as
16、effective,ineffective or harmful(or established as useful/predictive or not useful/predictive)for the given condition in the specified population.B=Probably effective,ineffective or harmful(or probably useful/predictive or not useful/predictive)for the given condition in the specified population.C=Possibly effective,ineffective or harmful(or possibly useful/predictive or not useful/predictive)for the given condition in the specified population.U=Data inadequate or conflicting;given current knowl
