CLINICAL REVIEW: Use of antiepileptic drugs in the treatment of chronic painful diabetic neuropathy.

CONTEXT: Up to 25% of individuals with diabetes develop painful diabetic neuropathy, suffering spontaneous pain, allodynia, hyperalgesia, and other unpleasant symptoms. Decreased physical activity, increased fatigue, and mood and sleep problems may result. EVIDENCE ACQUISITION: A MEDLINE search was conducted, limiting searching to double-blind, randomized, controlled trials (1978 to present) of antiepileptic drugs (carbamazepine, gabapentin, pregabalin, topiramate, and lamotrigine) used in the treatment of chronic neuropathic pain. EVIDENCE SYNTHESIS: The most important aspect of treatment is targeted at modification of the underlying disease. However, approaches to symptomatic pain control are essential and include multiple drug classes. Tricyclic antidepressants, including imipramine, nortriptyline, and amitriptyline, have been the mainstays of treatment, but anticholinergic effects, such as dry mouth, blurring of vision, constipation, orthostatic hypotension, and cardiac arrhythmias, as well as other adverse effects, often limit their use. Other treatments include capsaicin, clonidine, acupuncture, and electrical stimulation, suggesting that there is no single effective treatment. First-generation antiepileptic drugs have been shown to be effective in neuropathic pain. The evidence supporting the use of a new generation of antiepileptic drugs in painful diabetic neuropathy is reviewed.