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Neuropatia Diabética Periférica: Revisão Bibliográfica da Abordagem Terapêutica
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Introdução: A neuropatia diabética periférica (NDP) é uma das complicações mais
prevalentes da diabetes mellitus, afetando até 50% dos pacientes durante o curso da
doença. Caracteriza-se por alterações progressivas nos nervos periféricos, manifestandose inicialmente como dormência, formigueiro e dor em padrão distal, com progressão
para perda sensorial e risco aumentado de complicações graves, como úlceras e
amputações. Apesar das inúmeras opções terapêuticas disponíveis, o tratamento eficaz
da NDP permanece um desafio, especialmente nos casos refratários.
Objetivos: O presente trabalho tem como objetivo rever a informação existente sobre o
tratamento da NDP, incluindo terapias farmacológicas disponíveis e atualmente
utilizadas e as abordagens não farmacológicas, nomeadamente a estimulação da medula
espinhal (EME). Adicionalmente, com base na informação recolhida, sobre os últimos
avanços científicos, pretende-se criar um algoritmo de abordagem terapêutica.
Métodos: Procedeu-se a uma revisão bibliográfica exaustiva da informação existente
sobre o tema, recorrendo à base de dados PubMed/MEDLINE, B-on , Cochrane,
Dynamed e livros de referência na área da Medicina. Foram incluídos artigos na língua
portuguesa e inglesa publicados nos últimos 10 anos. Para a pesquisa utilizou-se uma
combinação dos termos “diabetic neuropathy”; “diabetes”; “pain management”;
“treatment” com recurso aos operadores booleanos "AND" e "OR". Incluíram-se artigos
de revisão, estudos prospetivos, meta-análises e ensaios clínicos, conduzidos unicamente
no ser humano, em especial aqueles centrados nas opções de tratamento farmacológico
e intervenções não farmacológicas, nomeadamente a EME. Foram consideradas apenas
as opções farmacológicas que seguem as Guidelines da American Diabetes Association
(ADA). Excluíram-se artigos de investigação realizados em animais e artigos que se
concentrassem no tratamento de outras formas de dor neuropática.
Conclusão: A revisão realizada destacou que as opções farmacológicas, como os
gabapentinóides, inibidores da recaptação de serotonina e noradrenalina (IRSN), e
antidepressivos tricíclicos (TCA’s), continuam a ser a base do tratamento da neuropatia
diabética periférica dolorosa (NDPd), com a pregabalina e a duloxetina emergindo como
os tratamentos de primeira linha recomendados pelas principais diretrizes, incluindo a
ADA. Os opióides devem ser usados com cautela devido aos seus efeitos adversos
significativos. Como abordagem não farmacológica, a EME mostrou-se uma intervenção
promissora, especialmente em casos refratários a tratamentos farmacológicos,
oferecendo alívio significativo da dor e melhoria da qualidade de vida dos pacientes. Com base nos achados, foi desenvolvido um algoritmo terapêutico, oferecendo uma
abordagem sistemática para a gestão da NDPd. Apesar dos avanços, foram identificadas
lacunas na literatura, particularmente relacionadas à eficácia a longo prazo das terapias
não farmacológicas e à necessidade de estudos mais robustos sobre combinações
terapêuticas. Esses resultados destacam a importância de continuar a investir em
pesquisas nesta área.
Introduction: Diabetic peripheral neuropathy (NDP) is one of the most prevalent complications of diabetes mellitus, affecting up to 50% of patients over the course of the disease. It is characterized by progressive alterations in the peripheral nerves, initially presenting as numbness, tingling, and distal-pattern pain, eventually progressing to sensory loss and an increased risk of severe complications such as ulcers and amputations. Despite the numerous therapeutic options available, the effective treatment of NDP remains a challenge, especially in refractory cases. Objectives: This study aims to review the existing knowledge on the treatment of NDP, including currently available pharmacological therapies and non-pharmacological approaches, particularly spinal cord stimulation (EME). Furthermore, based on the latest scientific advancements, it seeks to develop a therapeutic approach algorithm. Methods: A comprehensive literature review was conducted on the topic using the PubMed/MEDLINE, B-on, Cochrane, and Dynamed databases, as well as reference books in the field of Medicine. Articles in Portuguese and English published in the last 10 years were included. The search strategy involved a combination of the terms “diabetic neuropathy”, “diabetes”, “pain management”, and “treatment”, using the Boolean operators "AND" and "OR." The review included systematic reviews, prospective studies, meta-analyses, and clinical trials conducted exclusively in humans, with a particular focus on pharmacological treatment options and non-pharmacological interventions, especially spinal cord stimulation (EME). Only pharmacological treatments aligned with the American Diabetes Association (ADA) Guidelines were considered. Studies conducted on animals and articles focusing on the treatment of other forms of neuropathic pain were excluded. Conclusion: The review highlighted that pharmacological options, such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors (IRSN), and tricyclic antidepressants (TCA’s), remain the cornerstone of treatment for painful diabetic peripheral neuropathy (NDPd). Among these, pregabalin and duloxetine have emerged as first-line treatments recommended by major guidelines, including those of the American Diabetes Association (ADA). Opioids should be used with caution due to their significant adverse effects. As a non-pharmacological approach, spinal cord stimulation (EME) has proven to be a promising intervention, particularly in cases refractory to pharmacological treatments, providing significant pain relief and improving patients' quality of life. Based on the findings, a therapeutic algorithm was developed, offering a systematic approach to managing NDPd. Despite recent advancements, gaps in the literature remain, particularly regarding the long-term efficacy of non-pharmacological therapies and the need for more robust studies on combination treatments. These findings underscore the importance of continued research investment in this field.
Introduction: Diabetic peripheral neuropathy (NDP) is one of the most prevalent complications of diabetes mellitus, affecting up to 50% of patients over the course of the disease. It is characterized by progressive alterations in the peripheral nerves, initially presenting as numbness, tingling, and distal-pattern pain, eventually progressing to sensory loss and an increased risk of severe complications such as ulcers and amputations. Despite the numerous therapeutic options available, the effective treatment of NDP remains a challenge, especially in refractory cases. Objectives: This study aims to review the existing knowledge on the treatment of NDP, including currently available pharmacological therapies and non-pharmacological approaches, particularly spinal cord stimulation (EME). Furthermore, based on the latest scientific advancements, it seeks to develop a therapeutic approach algorithm. Methods: A comprehensive literature review was conducted on the topic using the PubMed/MEDLINE, B-on, Cochrane, and Dynamed databases, as well as reference books in the field of Medicine. Articles in Portuguese and English published in the last 10 years were included. The search strategy involved a combination of the terms “diabetic neuropathy”, “diabetes”, “pain management”, and “treatment”, using the Boolean operators "AND" and "OR." The review included systematic reviews, prospective studies, meta-analyses, and clinical trials conducted exclusively in humans, with a particular focus on pharmacological treatment options and non-pharmacological interventions, especially spinal cord stimulation (EME). Only pharmacological treatments aligned with the American Diabetes Association (ADA) Guidelines were considered. Studies conducted on animals and articles focusing on the treatment of other forms of neuropathic pain were excluded. Conclusion: The review highlighted that pharmacological options, such as gabapentinoids, serotonin-norepinephrine reuptake inhibitors (IRSN), and tricyclic antidepressants (TCA’s), remain the cornerstone of treatment for painful diabetic peripheral neuropathy (NDPd). Among these, pregabalin and duloxetine have emerged as first-line treatments recommended by major guidelines, including those of the American Diabetes Association (ADA). Opioids should be used with caution due to their significant adverse effects. As a non-pharmacological approach, spinal cord stimulation (EME) has proven to be a promising intervention, particularly in cases refractory to pharmacological treatments, providing significant pain relief and improving patients' quality of life. Based on the findings, a therapeutic algorithm was developed, offering a systematic approach to managing NDPd. Despite recent advancements, gaps in the literature remain, particularly regarding the long-term efficacy of non-pharmacological therapies and the need for more robust studies on combination treatments. These findings underscore the importance of continued research investment in this field.
Descrição
Palavras-chave
Diabetes Mellitus Dor Crónica. Estimulação da Medula Espinhal Neuropatia Diabética Neuropatia Periférica Terapia
Farmacológica Tratamento