Podiatry : Diabetic Neuropathy

Neuropathic pain includes a variety of conditions such as diabetic neuropathy, phantom limb pain, reflex sympathetic dystrophy (RSD or Complex Regional Pain Syndrome), and pain caused by blunt trauma or crushing injuries. Symptoms of neuropathic pain may not be evident for weeks to months after the injury. Optimal treatment may involve not only the use of traditional analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, but may also include medications that possess pain-relieving properties, including some antidepressants, anticonvulsants, antiarrhythmics, anesthetics, antiviral agents, and NMDA antagonists. “Combination therapy is frequently the only effective approach for managing the complex array of chemical mediators and other contributors to the individual pain experience.”1

“As topical formulations are developed, they provide hope for more effective drug combinations, with fewer systemic adverse drug effects and drug-drug interactions.”1 For example, research has shown that topically applied ketoprofen provides a high local concentration of drug below the site of application but decreases systemic exposure and significantly reduces the risk of gastrointestinal upset or bleeding. When properly compounded into an appropriate base, tissue concentrations of ketoprofen were found to be 100-fold greater below the application site (knee) compared to systemic concentrations.2 Sever disease is the most common cause of heel pain in pre-pubertal children. A case report described the use of topical ketoprofen 10% gel as an adjunct to physical therapy to relieve pain and inflammation.3

1 Advanced Studies in Medicine 2003 July;3(7A):S639
2 Pharmaceutical Research (1996) 13: 1; 168-172
3 Phys Ther. 2006 Mar;86(3):424-33


Neuropathy Foot Cream

The following testimonial appeared in the December 1999 issue of Neuropathy News, a patient newsletter:

"My local [compounding pharmacist] has created a cream to help alleviate the pain of foot neuropathy. It reduces the burning and sharp, needle-like pain. All you need is a very thin coat. The directions call for using it four times a day, but I find it particularly helpful at night. [The formulation contains] 2% amitriptyline and 2% baclofen in a transdermal gel."
"Compounding pharmacists have the unique training and ability to create medications that address the individual needs of patients. One of the most helpful products they use are transdermal gels that allow for the passage of medication directly through the tissue into the area of pain. Many of the medications typically prescribed for neuropathy patients such as amitriptyline, lidocaine, mexilitene, ketamine and [gabapentin] can cause significant side effects when taken orally. Transdermal gel minimizes systemic side effects and maximizes local pain relief. Compounding pharmacists have many resources that offer relief from neuropathic pain."

In Diabetes Interviews, January 2000, Neil A. Burrell, DPM, CDE, of Beaumont, Texas, writes "We have a very high success rate using amitriptyline and baclofen mixed in a gel component. This compound is applied to the feet three times per day, and offers immediate relief... [For] recalcitrant neuropathic pain, many times we use a combination of tramadol, gabapentin and amitriptyline."

At our compounding pharmacy, we work together with physicians and patients to prepare formulations containing the medications and doses that are most appropriate to meet each patient's specific needs. Let us know how we can be of service.

Arginine Transdermal
Diabetes Care, January 2004; 27(1):284-5
Improvement of Temperature and Flow in Feet of Subjects with Diabetes With Use of a Transdermal Preparation of L-Arginine - A pilot study

Eric T. Fossel, PHD
Strategic Science and Technologies, Wellesley, Massachusetts
PubMed PMID: 14694013 No abstract available.

Topical doxepin could be an alternative and relatively safe treatment in alleviating neuropathic pain in the diabetic patient, especially when the use of systemic treatment is contraindicated. In the following case study, the soles of the patient’s feet were treated with topical doxepin 5% twice daily for four weeks. The patient responded dramatically with loss of the severe burning sensation and no side effects reported.

Wounds 15(8):272-276, 2003. © 2003 Health Management Publications, Inc.
Burning Feet Due to Diabetic Neuropathy

Amna Al-Muhairi, MD, Tania J. Phillips, MD, FRCPC
The print version of this article was originally certified for CME credit. For accreditation details, contact the publisher. Tanya J. Phillips, MD, FRCPC, Boston University School of Medicine, Department of Dermatology, 609 Albany Street, J-106, Boston, MA 02118; Phone: 617/638-5540, Fax: 617/638-5552