Where does spinal cord stimulation fit into the international guidelines for refractory painful diabetic neuropathy? a consensus statement

A J M Boulton; T S Jensen; T Luecke; E A Petersen; R Pop-Busui; R S Taylor; S Tesfaye; L Vileikyte; D Ziegler

doi:10.1016/j.diabres.2023.110763

Where does spinal cord stimulation fit into the international guidelines for refractory painful diabetic neuropathy? a consensus statement

Diabetes Res Clin Pract. 2023 Dec:206 Suppl 1:110763. doi: 10.1016/j.diabres.2023.110763.

Authors

A J M Boulton¹, T S Jensen², T Luecke³, E A Petersen⁴, R Pop-Busui⁵, R S Taylor⁶, S Tesfaye⁷, L Vileikyte⁸, D Ziegler⁹

Affiliations

¹ University of Manchester, Manchester, UK. Electronic address: ABoulton@med.miami.edu.
² International Diabetic Neuropathy Consortium, Aarhus University, Aarhus, Denmark.
³ Pain Center, Franziskus Hospital Linz, Vice President, German Pain Society, Linz am Rhein, Germany.
⁴ University of Arkansas for Medical Sciences, AR, USA.
⁵ Metabolism, Endocrinology, and Diabetes, University of Michigan, MI, USA.
⁶ University of Glasgow, Glasgow, UK.
⁷ Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, UK.
⁸ University of Manchester, Manchester, UK.
⁹ Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.

PMID: 38245326
DOI: 10.1016/j.diabres.2023.110763

Abstract

Background: Although pharmacotherapy with anticonvulsants and/or antidepressants can be effective for many people with painful diabetic neuropathy (PDN), albeit with frequent side-effects, a critical juncture occurs when neuropathic pain no longer responds to standard first- and second-step mono- and dual therapy and becomes refractory. Subsequent to these pharmacotherapeutic approaches, third-line treatment options for PDN may include opioids (short-term), capsaicin 8% patches, and spinal cord stimulation (SCS).

Aim: This document summarizes consensus recommendations regarding appropriate treatment for refractory peripheral diabetic neuropathy (PDN), based on outcomes from an expert panel convened on December 10, 2022, as part of the Worldwide Initiative for Diabetes Education Virtual Global Summit, "Advances in the Management of Painful Diabetic Neuropathy."

Participants: Nine attendees, eminent physicians and academics, comprising six diabetes specialists, two pain specialists, and one health services expert.

Evidence: For individuals with refractory PDN, opioids are a high-risk option that do not provide a long-term solution and should not be used. For appropriately selected individuals, SCS is an effective, safe, and durable treatment option. In particular, high-frequency (HF) SCS (10 kHz) shows strong efficacy and improves quality of life. To ensure treatment success, strict screening criteria should be used to prioritize candidates for SCS.

Consensus process: Each participant voiced their opinion after reviewing available data, and a verbal consensus was reached during the meeting.

Conclusion: Globally, the use of opioids should rarely be recommended for refractory, severe PDN. Based on increasing clinical evidence, SCS, especially HF-SCS, should be considered as a treatment for PDN that is not responsive to first- or second-line monotherapy/dual therapy.

Keywords: Diabetic neuropathy; Health-related quality of life; Spinal cord stimulation.

MeSH terms

Diabetes Mellitus*
Diabetic Neuropathies* / diagnosis
Humans
Neuralgia* / etiology
Neuralgia* / therapy
Quality of Life
Spinal Cord Stimulation*
Treatment Outcome