Table 2 – Types of Peripheral Neuropathy & Exam Findings1

Type Comments/Exam Findings
Distal Symmetric Polyneuropathy • Length-dependent: diffuse involvement, affects distal segments first
• Symptoms occur below the knees prior to affecting fingers
• Most common cause: diabetes
Mononeuropathy • Symptoms restricted to distribution of single nerve, myotome, or dermatome
• Asymmetric reflexes
Mononeuropathy Multiplex • Occurrence of several concurrent mononeuropathies
• Vasculitic etiology
Hereditary Neuropathies • Distal calf atrophy, hammertoes, pes cavus
• Motor deficits ≥ sensory deficits
• Diffuse areflexia
Radiculopathy • Degenerative disease affecting cervical or lumbosacral spine
• Asymmetric reflexes
• Lower back pain, pain radiating to legs, bladder/bowel dysfunction
Myelopathy • Disease affecting spinal cord
• Hyperreflexia, spasticity, sensory deficits occurring in the trunk

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Table 3 – Pharmacologic Options for Peripheral Neuropathy1

Medcation Goal Dose Evidence Comments
Gabapentin 300mg TID • Not more effective than placebo • Good for patients with a seizure disorder; avoid in patients with renal insufficiency
• AEs: dizziness, drowsiness, balance/gait disturbance, confusion, peripheral edema
Pregabalin 150mg BID • More effective than placebo
• Similar efficacy to TCAs
Amitriptyline and Nortriptyline 50-100mg at bedtime • Found to be more effective than placebo
• Similar efficacy to pregabalin and SNRIs
• Good for patients with insomnia, migraine; avoid in patients with cardiac issues or taking serotonergic medications
• AEs: dry mouth, drowsiness, dizziness, confusion, QT prolongation, orthostatic hypotension
Duloxetine 60mg/day • More effective than placebo and pregabalin
• Similar efficacy to TCAs
• Good for patients with anxiety, depression, or fibromyalgia; avoid in patients with hepatic failure or taking serotonergic medications or anticoagulants
• AEs: nausea, indigestion, constipation, dizziness, dry mouth, hyperhidrosis, sexual dysfunction
Venlafaxine 150mg daily (XR) • More effective than placebo and pregabalin
• Similar efficacy to TCAs
• Good for patients with anxiety or depression; avoid in patients with uncontrolled hypertension or taking serotonergic medications
• AEs: nausea, indigestion, drowsiness, nervousness, hypertension, sexual dysfunction
Opiates • Not effective in the treatment of painful diabetic neuropathy • Associated with increased rates of depression, medication dependence, overdose, use of gait assist-devices
• Found to worsen functional status
Atypical Opiates (tramadol, tapentadol) • More evidence to support use versus typical opiates • Can be used if first-line agents fail
Topical Therapies (capsaicin cream/ patches, lidocaine patches, percutaneous electrical nerve stimulation, botulinum toxin) • Second-line agents if pain is localized
• Lower risk of systemic AEs and drug interactions

Abbreviations: AEs (adverse events); BID (twice daily); TID (three times daily); SNRIs (serotonin-norepinephrine reuptake inhibitors); TCAs (tricyclic antidepressants)