02/13/2025 Allen M. Jacobs, DPM
Fall Risk Assessment When Choosing Between Gabapentin and Duloxetine (Paul Kesselman, DPM)
Dr. Kesselman has asked PM readers to comment
regarding their experience with commonly utilized
medications for the treatment of symptomatic
diabetic sensory neuropathy and risk of falls. I
should like to share my approach to this problem.
Frequently, the symptoms of symptomatic diabetic
neuropathy are exacerbated or occur primarily
during the evening hours. Therefore, in many
patients I will prescribe a shorter acting
adjunctive analgesic (e.g.-pregabalin, gabapentin,
or a tricyclic antidepressant) at bedtime,
reducing or eliminating the risk of falls.
Oftentimes, a relatively low dosage, almost sub-
theraputic dosage, may be sufficient to provide
the patient with a restful, restorative nights
sleep and improve quality of life.
Another strategy is to combine an adjunctive
analgesic (eg-duloxetine, pregabalin) with another
agent such as alpha lipoic acid or benfotiamine.
This allows use of a lower dosage of the "at-risk"
medication, and not infrequently a synergistic
effect may be noted. Both alpha lipoic acid and
benfotiamine are approved for the treatment of
diabetic neuropathy in Europe, and are effective
when given at an appropriate dosage. Oftentimes
the correct supplements are given but in an
inadequate dosage.
Yet another strategy is to combine an adjunctive
analgesic with a compounded topical medication,
thus allowing the clinician to employ a lower
dosage of the potentially fall producing
medications. Many of the compounded medications
are quite effective by themselves in providing
relief of pain from symptomatic diabetic
neuropathy.
There are a variety of less commonly employed
therapies which may also assist in the resolution
of symptomatic diabetic sensory neuropathy,
ranging from acupuncture to TCNS to scrambler
therapy.
In the patient taking metformin (as well as those
with diabetic neuropathy not on metformin), folic
acid and B12 deficiency is not uncommon, and
supplementation in such patients may help
ameliorate diabetic sensory neuropathy symptoms.
Other therapies may include L-carnitine, vitamin D
(particularly in minority patients, gamma amino
linoleic acid. All of these therapies may assist
in reducing the dosage of gabapentinoids or
SSNRI's or TCA's needed to resolve symptomatic
diabetic neuropathy.
While the use of any psycho-active medication
would be anticipated to increase fall risk, it is
also true that diabetes itself, with sensory,
motor, autonomic neuropathy, is associated with
significant fall risk. Painful neuropathy further
increases fall risk in such patients. Additional
confounding factors include visual difficulties,
eighth cranial nerve disease, spinal stenosis,
peripheral nerve entrapments, gait alteration due
to musculoskeletal disease, sarcopoenia, other
medications (eg-antihypertensives). Fall risk
assessment and gait evaluation should be a part of
the "comprehensive diabetic foot evaluation".
Finally, a would suggest the readers review the
most recent recommendations of the American
Academy of Neurology, or the recent review by
Boulton et al in Diabetes Care of the management
of symptomatic diabetic neuropathy. It is
interesting to note how "edgy" therapies such as
supplements, vitamins, vibration therapy, topical
therapies have garnered increasing literature
support and become "acceptable" alternatives in
the treatment of diabetic neuropathy.
I have found the treatment of diabetic neuropathy
to be rewarding in improving the quality of life
for many patients. One can also provide additional
office revenue through the expanded office
services and when indicated and appropriate,
dispensing needed products. The key in my opinion
is patient education. Many patients have little
knowledge or understanding of their neuropathy,
and spending time to educate the patient and/or
family members, in my experience, yields greater
adherence to recommended treatment protocols.
Allen M. Jacobs, DPM, St. Louis, MO
