Call to Action on Painful Diabetic Neuropathy in Arab World

v o l u m e 12 n u m b e r 4
FALL 2013
Practical
Information
for Primary
Care
Status of Painful Diabetic Peripheral Neuropathy
in the Arab World :A Call to Action
Monira Al-Arouj, MD; Samir H. Assaad-Khalil, MD, PhD; Ebtesam
M Ba-Essa, FRCP; Megahed Abu El-Magd, MD; Mohamed Fahmy,
MD, PhD., Martha Funnell, PhD; Sherif Hafez, MD, FACP; Mahmoud
Ibrahim, MD; Abdulrazzaq Al-Madani, MD; Abdullah Ben Nakhi, MD;
Gamela Nasr, MD ; Abraham Thomas , MD, FACP
[Middle East Edition]

177 Volume 12, Number 4, 2013 • CLINICAL DIABETES (MIDDLE EAST EDITION)
L O C A L A R T I C L E S
Status of Painful Diabetic Peripheral Neuropathy
in the Arab World :A Call to Action
Monira Al-Arouj, MD1
; Samir H. Assaad-Khalil, MD, PhD2
; Ebtesam M Ba-Essa, FRCP3
; Megahed Abu El-Magd,
MD4
; Mohamed Fahmy, MD, PhD5
., Martha Funnell, PhD6
; Sherif Hafez, MD, FACP7
; Mahmoud Ibrahim, MD8
;
Abdulrazzaq Al-Madani, MD9
; Abdullah Ben Nakhi, MD1
; Gamela Nasr, MD10
; Abraham Thomas , MD, FACP11
1
Dasman Diabetes Institute, Kuwait; 2
Department of Internal Medicine, Unit of Diabetes & Metabolism, Faculty of
Medicine, Alexandria University, Egypt; 3
Dammam Medical Complex, Dammam, Saudi Arabia; 4
Department of Internal
Medicine & Endocrinology, Faculty of Medicine, Mansura University, Mansura, Egypt; 5
Department of Internal Medicine
& Endocrinology, Faculty of Medicine, Ain Shams University, Cairo, Egypt; 6
Department of Medical Education, University
of Michigan Medical School, Michigan, USA; 7
Department of Internal Medicine & Diabetes, Faculty of Medicine, Cairo
University, Cairo, Egypt; 8
EDC Center for Diabetes Education, McDonough, GA , USA; 9
Dubai Hospital, Dubai, United
Arab Emirates; 10
Department of Cardiology, Suez Canal University, Egypt; 11
Division Head Endocrinology, Diabetes, Bone &
Mineral Disorders, Whitehouse Chair in Endocrinology, Henry Ford Hospital, Detroit MI, USA.
Abstract
Diabetes is one of the most challeng-
ing health problems with its incidence
and prevalence rising in almost every
country in the world. However, the
prevalence in the Arab region has
been the highest. The prevalence of
painful diabetic peripheral neuropa-
thy (DPN) among type 1 or type 2
diabetic adults in the Arab countries
is very high.
Because of the high prevalence and
associated impact on the quality of
life, disability, and economic impact
of painful DPN, it was recommended
that diabetic patients should be
periodically screened, using a simple
instrument such as the DN4, and
receive appropriate treatment as
soon as symptoms and signs appear.
Educational programs concerning
painful DPN should target key phy-
sician leaders and educators so they
can be trained to train the others.
These programs should be designed
to enables these key doctors to
deliver the same educational content
to the primary health care providers
including, but not limited to fam-
ily physicians, nurses and diabetes
educators.
Also campaigns to target lay people
should be developed, using the
suitable tools adapted for each com-
munity, to increase public awareness
of the diabetic neuropathic pain
problem and possible ways of pre-
vention with a special focus on the
need for glycemic control
Keywords: Painful Neuropathy, Arab
World.
Corresponding Author Details:
Mahmoud Ibrahim, MD Director
EDC, Center for Diabetes
Education, McDonough, GA, USA.
mahmoud@arab-diabetes.com
Diabetes in the Arab countries
Diabetes is undoubtedly one of the
most challenging health problems,
where its incidence and prevalence
are rising approximately in every
country of the world. However, the
prevalence seen in the Arab region
has been the highest 1. Current
data shows that almost 20.5 mil-
lion people from 20 Arab countries
are diabetics, and 13.7 million are
in the pre-diabetes stage. This high
prevalence of diabetes is reflected
by the finding that five of the top 10
countries with the greatest diabetes
prevalence in subjects 20-79 years
old were actually from the Arab
region1. Population-based diabetes
studies have shown that the preva-
lence of diabetes in these countries
was 23.9% in Kuwait, 23.4% in
Saudi Arabia, 23.3% in Qatar and
22.4% in Bahrain1. The age-specific
prevalence of diabetes shows that
in developed countries, most people
with diabetes are above the age of
retirement, while in Arab countries;
approximately 73% of people with
diabetics are younger than sixty.
This younger age could significantly
increase disability due to diabetes
in a younger and more likely to be
working population, making the
impact even greater1.
Despite the emphasis on glycemic
control, evidence of improvement in
A1C control over time remains scant.
in Egypt Only 16.5% of patients
had A1C < 7% and 28.5% of them
had very poor glycemic control as
represented by an A1C > 9%.2
A screening campaign of 197,681
participants in an eastern province
of Saudi Arabia, demonstrated an
estimated prevalence of diabetes
of 15.7%. However, only 33.8% of
patients with diabetes achieved their
glycemic control targets (fasting
blood glucose less than 130 mg/dl or

178Volume 12, Number 4, 2013 • CLINICAL DIABETES (MIDDLE EAST EDITION)
random capillary blood glucose less
than 180 mg/dl). Multiple logistic
regression analysis showed that
higher age, current smoking and
lower level of physical activity were
significantly associated with uncon-
trolled diabetes.3 Another study
in Saudi Arabia revealed that only
27% of people with type 2 Diabetes
reached their glycemic target (A1C <
7%).4
Painful Diabetic Peripheral
Neuropathy
The neuropathies developing in
patients with diabetes are known to
be heterogeneous by their symptoms,
pattern of neurologic involvement,
and course. An internationally
agreed definition of Diabetic Painful
Neuropathy DPN for clinical prac-
tice is: the presence of symptoms and/
or signs of peripheral nerve dysfunc-
tion in patients with diabetes after
a careful clinical examination of the
lower extremities and the exclusion
of other causes. However, not all
patients with peripheral nerve dys-
function have a neuropathy caused
by diabetes. Confirmation can be
established with quantitative electro-
physiology, sensory, and autonomic
function testing 5-6-7.
How should the severity of a patient's
polyneuropathy be assessed? The
severity of a patient's polyneuropathy
is obviously the sum of the patient's
symptoms, neurological signs, test
abnormalities, dysfunctions and
other adverse outcomes. Numerous
classifications have been proposed
in the recent years, which have been
based mainly on one originally
proposed by Thomas.8
Separate definitions for typical
Diabetic sensorimotor polyneu-
ropathy DPN (DSPN) and atypical
DPNs were proposed by Tesfaye and
Boulton, et al. DSPN is a symmetri-
cal, length-dependent sensorimotor
polyneuropathy attributable to meta-
bolic and microvascular alterations
as a result of chronic hyperglycemia
exposure (diabetes) and cardiovas-
cular risk covariates accompanied by
an abnormality of nerve conduction
tests, which is frequently subclinical.
Coexisting retinopathy and nephrop-
athy strengthen the diagnosis after
exclusion of other causes of senso-
rimotor polyneuropathy. 5
For epidemiologic surveys or con-
trolled clinical trials of DSPN, it is
advocated to use appropriate nerve
conduction (NC) testing as an early
and confirmed diagnosis of the occur-
rence of DSPN. On the other hand,
atypical DPNs have been less well
characterized and studied. Composite
scores of neuropathy symptoms,
signs, neurophysiologic test abnor-
malities, and other dysfunctions and
impairments may provide an indica-
tion of its severity 9-10
An alternative approach for esti-
mating the severity is to define this
severity by grades. Dyck described
the stages of severity ranging from
Grade 0 where there is no abnormal-
ity in the NC up to Grade 2b where
the NC abnormality is accompanied
by a moderate degree of weakness
(i.e. 50%) of ankle dorsiflexion with
or without neuropathy symptoms. 11
However, definitions of typical DPN
are: 1- Possible DSPN where you
can find the presence of symptoms or
signs of DSPN including decreased
sensation, positive neuropathic
sensory symptoms predominantly
in the toes, feet, and/or legs; or signs
such as a symmetric decrease in distal
sensation or unequivocally decreased
or absent ankle reflexes. 2-Probable
DSPN which is a combination of
symptoms and signs of neuropathy,
including any two or more neu-
ropathic symptoms, decreased
distal sensation, or unequivocally
decreased or absent ankle reflexes.
3-Confirmed DSPN is the pres-
ence of an abnormality of NC and
symptom(s) and/or sign(s) of neu-
ropathy. If NC is normal, a validated
measure of small fiber neuropathy
(SFN) may be used. To assess for
the severity of DSPN, you need to
sum the scores of neurologic signs,
symptoms or nerve test scores, scores
of function of acts of daily living or
of predetermined tasks or of disabil-
ity. 4- Subclinical DSPN it is the lack
of signs or symptoms of neuropathy
with abnormal NC(s) or a validated
measure of SFN. It is recommended
that definitions 1, 2, or 3 be used for
clinical practice and definitions 3 or 4
be used for research studies. 12-13-14
Atypical DPNs
Before further classification of these
polyneuropathies, setting the mini-
mal criteria for diagnosis, estimating
the severity of neuropathy, and
further studies characterizing the
epidemiology and mechanisms are
needed. 14
PAINFUL DPN
is pain arising as a direct consequence
of abnormalities in the peripheral
somatosensory system in people with
diabetes, which was adapted from a
definition recently proposed by the
International Association for the
Study of Pain. 12 Its prevalence in
the diabetic population is difficult to
estimate as definitions have varied
enormously among studies; however,
it is roughly estimated that between
3 and 25% of patients might experi-
ence neuropathic pain (NP) with
limited data on the natural history.
13 In practice, the diagnosis of
painful DPN is a clinical one, which
relies on the patient’s description
of pain. The symptoms are distal,
symmetrical, often associated with
nocturnal exacerbations, and com-
monly described as prickling, deep
aching, sharp, like an electric shock,
and burning with hyperalgesia and
frequently allodynia upon examina-
tion. 13 The symptoms are usually
associated with the clinical signs of
peripheral neuropathy, although
occasionally in acute painful DPN,
the symptoms may occur in the
absence of the typical signs. A num-
ber of simple numeric rating scales
can be used to assess the frequency
and severity of painful symptoms.
14 After exclusion of other causes of
neuropathic pain NP. The severity
of pain can be reliably assessed by
the old and validated visual analog

scale, or the widely used numerical
rating scale, e.g. the 11-point Likert
scale ranging from (0 _ no pain, 10 _
worst possible pain). Quality of life
(QoL) improvement should also be
assessed, preferably using a validated
neuropathy-specific scale such as
Neuro-QOL or the Norfolk Quality
of Life Scale. 15 Outcomes must be
measured using patient-reported
improvement in scales for pain
and QoL as measured on validated
instruments. External observers can
play no part in the assessment of the
subject’s responses to the new thera-
pies for NP; thus, measures such as
the “physician’s global impression of
response” are not valid.
Painful neuropathy in the Arab
countries
In a step to determine the preva-
lence of painful DPN in the Arab
countries, the main objective of a
recent study done by Jambart and his
colleagues was to determine the prev-
alence of painful DPN among type
1 or type 2 diabetic adults attend-
ing outpatient clinics in the Middle
East Region, specifically Egypt,
Lebanon, Jordan and the Gulf
States of Kuwait and the United
Arab Emirates (n = 4097.) Overall,
53.7% of 3989 patients with DN4
data met the criteria for painful DPN
(Douleur Neuropathique-4 [DN4]
scores ≥4). The symptom ranged
from itching (23.1%) to burning sen-
sation (59.3%) including hypothesia,
painful cold, electric shock, tingling
and numbness (Figure 1). Significant
predictors of painful DPN included
longer duration (≥10 years) of dia-
betes (odds ratio [OR] 2.43), age ≥65
years (OR 2.13), age 50 – 64 years
(OR 1.75), presence of type 1 versus
type 2 diabetes (OR 1.59), body
mass index ≥30 kg/m2 (OR 1.35) and
female gender (OR 1.27). Living in
one of the Gulf States was associ-
ated with the lowest odds of having
painful DPN (OR 0.44). The odds
of painful DPN were highest among
patients with peripheral vascular dis-
ease (OR 4.98), diabetic retinopathy
(OR 3.90) and diabetic nephropathy
(OR 3.23) (Figure 2.) Because of the
high prevalence, associated suffering,
disability and economic burden of
painful DPN, it was recommended
that diabetic patients should be
periodically screened, using a simple
instrument such as the DN4, and
receive appropriate treatment as
early as the symptoms and signs start
to appear. 16
Treatment of Painful Diabetic
Neuropathic Pain
There are many available treat-
ment options; however, a rational
approach to treating the patient
with painful DPN requires an
understanding of the evidence for
each intervention. Pharmacological
management of painful DPN almost
exclusively consists of symptomatic
therapies improving symptoms
without an effect on underlying
causes or natural history 17. The
antioxidant lipoic acid administered
intravenously is the only pathogenic
treatment that has efficacy confirmed
from several randomized controlled
trials and in a meta-analysis18.
Again Level A evidence supports
the use of tricyclic antidepres-
sants (e.g., amitriptyline) 21, the
anticonvulsants gabapentin and
pregabalin, and the serotonin and
norepinephrine reuptake inhibitor
duloxetine 17-20-22-23. On the other
hand there are also randomized
controlled trials (RCT) supporting
the use of opiates, such as oxycodone
and tramadol in painful DPN 17-20.
However in another study, there
was no evidence to support the use
of the cannabinoids 24. Thus, it is
recommended that first line therapy

for painful DPN could be a tricyclic
antidepressant, duloxetine, prega-
balin, or gabapentin, after careful
consideration of individual patient
comorbidities and the cost of the
drug 17-20-22. Combinations of the
first-line therapies could be an option,
if significant pain persists , after
initiation of first-line monotherapy
17-20. If these changes and combined
therapy do not control the pain, , opi-
oids, like tramadol and oxycodone,
may be considered in combination
with first-line therapies as part of the
treatment plan 17-20. Preliminary
evidence shows promise for topical
treatment, using a 5% lignocaine
plaster applied to the most painful
area 25, although larger RCTs are
required. Non-pharmacological
treatments, such as spinal cord stimu-
lation, might be useful in refractory
painful DPN, 19 however, insufficient
evidence exists for any other non-
pharmacological therapies.
Old and New drugs
Although several novel analgesic
drugs have recently been introduced
into clinical practice, the pharma-
cologic treatment of chronic DPN
remains a challenge for the physi-
cian. Individual tolerability remains
a major aspect in any treatment
decision. Advanced knowledge in the
neurobiology of neuropathic pain
and an increasing perception of the
commercial value of analgesic agents
have led to a real need for research
develops to novel pharmaceutical
approaches. According to a recent
review 26, at least 50 new molecular
entities have reached the clinical stage
of development, including glutamate
antagonists, cytokine inhibitors,
vanilloid-receptor agonists, cat-
echolamine modulators, ion-channel
blockers, anticonvulsants, opioids,
cannabinoids, COX inhibitors,
acetylcholine modulators, adenos-
ine receptor agonists, and several
miscellaneous drugs. Eight drugs are
presently in phase III trials. Strategies
that may show promise over existing
treatments include topical therapies,
analgesic combinations, and, in the
future, gene- related therapies 26.
Whether the efficacy and safety
differ between the newer and older
compounds has not been systemati-
cally addressed in comparative trials,
although clinical experience indi-
cates that the rates of adverse events
(AEs) of the newer compounds may
be lower than those of the older ones,
such as tricyclic antidepressants.
Almost no information is available
from controlled trials on long-term
analgesic efficacy. Only few stud-
ies have used drug combinations,
indicating that the latter may result
in enhanced efficacy. 26
There are many unanswered ques-
tions and areas relating to painful
DPN that warrant further investiga-
tion, including population-based
prevalence and natural history stud-
ies, trials using active comparators
rather than placebo, assessment of
combination therapies in addition to
placebo, and longer-term studies of
the efficacy and durability of treat-
ments of painful DPN 26
Recently a multidisciplinary panel
, including key physicians and
researchers concerned with neu-
ropathic pain in the Middle East
area along with an international
Figure 1 & 2 reproduced with permission of the JIMR

panel, met together to review the
most recent data in an attempt
to form a consensus for evidence
based guidelines to treat DPN
(mainly peripheral painful DPN)
in patients from the Middle East.
This expert panel recommended
pregabalin, gabapentin and second-
ary amine tricyclic antidepressants
(nortriptyline and desipramine) as
first-line treatments for peripheral
DPN. Serotonin–norepinephrine
reuptake inhibitor antidepressants,
tramadol and controlled-release
opioid analgesics were preferred by
the same panel to serve as second line
treatments. They also addressed the
need to increase diagnostic awareness
of DPN , use validated screening
questionnaires, and undertakes more
research on treatment in the Middle
East region27
The Role of Diabetes Education and
the Diabetes Educator
The provision of comprehensive
diabetes self-management educa-
tion as well as specific information
about neuropathy and foot-care is
recommended as part of the on-going
clinical care of diabetes.28,29 All
patients with diabetes need general
education about long-term complica-
tions and foot care. Patients who
have high risk foot conditions, such
as neuropathy, need to understand
their personal risk factors and
specific strategies to prevent further
damage.28,30,31
Education about appropriate foot
care is particularly important for
patients who are at high risk. 30
and has been shown to positively
influence foot care behavior in the
short-term. 31 Patients with neu-
ropathy and other high-risk foot
conditions need to understand the
implications of decreased sensa-
tion, the importance of appropriate
footwear and daily foot inspection,
how to effectively care for their feet
and when to seek care.28
Foot care education has the poten-
tial to prevent further damage and
the ulcerations that can lead to
amputations, other morbidities and
mortality. While all health care pro-
fessionals who provide diabetes care
need to provide this information, the
diabetes educator can play a key role
in providing effective education. The
role of the educator is particularly
important in busy practices where
foot care education can become
secondary to medical management.
As part of initial education,
the diabetes educator can:
• Provide information about
potential complications, includ-
ing neuropathy and prevention
strategies, such as blood glucose
management.
• Teach patients to identify symp-
toms that could be linked to
neuropathy and when to report
them to the provider, stressing the
importance of early detection to
prevent further damage. Because
many symptoms are vague and
may not be recognized by patients
as linked to diabetes or nerve
damage, this is a particularly
important role for the educator.
• Teach patients initial foot
care strategies, such as remov-
ing shoes and socks at all
diabetes-related visits to facilitate
examination and reminding
providers of the need for an
annual comprehensive exam.
In addition, home care, such as
appropriate daily care and foot-
wear are initial education topics
the educator can address.
As part of continuing education,
• Review prevention strategies for
complications and symptoms to
report to physicians.
• Conduct foot inspections and to
screen for neuropathy (checking
pulses, reflexes and sensation
with a monofilament) using
standard screening instruments
. http://www.med.umich.edu/
mdrtc/profs/survey.html#mnsi
After the diagnosis of neuropathy,
• Assist patient to cope with the
bad news of a complication.
Offer reassurance that amputa-
tions are not an inevitable result.
32
• Provide information about medi-
cations available for pain relief
and other strategies to ease pain
(e.g. keeping bed covers away
from painful feet).
• Emphasize the critical impor-
tance of foot care and provide
personalized strategies to prevent
trauma. Stress the importance
of protecting the feet, inspecting
for injury and seeking prompt
treatment for any issues.
• Work with the patient to create
a daily plan for foot care that
accommodates the patient’s
physical findings, schedule,
lifestyle and culture.
Recommendations
In the Arab countries, the high
prevalence of the Diabetic Painful
Neuropathy is actually leading to
significant morbidity and disability,
which could also create an economic
burden. Accordingly, there is a great
need to tackle this problem , even
though DPN may not be life threaten-
ing issue, such as the macrovascular
complications of diabetes. Yet DPN
negatively impacts the quality of life.
The recommendations included
hereunder provide guidance on
appropriate care and measures that
can be modified according to suit the
needs of each country.
A) The Establishment of Painful
Neuropathy Leaders:
Programs should be targeting key
doctors concerned with painful
neuropathy in a way to train the
trainers. These programs should
be designed in a way to enables
these key doctors to deliver the
same materials and messages to
the primary health care provid-
ers in their area, including, but
not limited to family physicians ,
nurses, and diabetes educators.
B) Lay people
targeted campaigns should be
designed using the suitable tools

for each community aiming to
increase public awareness of the
neuropathic pain problem and the
possible ways of prevention with
a special focus on the glycemic
control.
For a more in depth and recent
review of diabetic neuropathy33
Disclosure:
Authors of this article have no
relevant financial relationships to
disclose.
This article is a part of an edu-
cational activity supported &
sponsored without restriction by
Pfizer.
References
1. International Diabetes
Federation. IDF diabetes atlas,
5th Edition, 2011
2. Samir H Assaad-Khalil, Adel
Zaki, Magdy H Megallaa.
Assessment of Patients
Characteristics, Metabolic
Control and Therapeutic
Management of Diabetic
Patients in Egypt: Results from
the Cross-sectional Wave-2006
of the International Diabetes
Management Practices Study
(IDMPS). ICIUM Congress,
Antalya, Turkey, November
2011.
3. Al-Baghli NA, Al-Turki KA,
Al-Ghamdi AJ, El-Zubaier AG,
Al-Ameer MM, Al-Baghli FA.
Control of diabetes mellitus
in the Eastern Province of
Saudi Arabia: results of screen-
ing campaign. East Mediterr
Health j 2010 Jun;16(6):621-9.
4. Abdulmohsen H. Al-Elq.
Current practice in the man-
agement of patients with
type 2 diabetes Mellitus in
Saudi Arabia. Saudi Medical
Journal. Saudi Med J. 2009
Dec;30(12):1551-6
5. Solomon Tesfaye, Andrew J.M.
Boulton, Rayaz A. Malik, On
behalf of the Toronto Diabetic
Neuropathy Expert Group .
Diabetic Neuropathies: Update
on Definitions, Diagnostic
Criteria, Estimation of Severity,
and Treatments. Diabetes Care.
2010;33:2285–2293
6. Andrew J.M. Boulton , Arthur
I. Vinik , Joseph C. Arezzo
, Diabetic Neuropathies , A
statement by the American
Diabetes Association Diabetes
Care. 2005;28:956–962
7. Vinik AI, Maser RE, Mitchell
BD, Freeman R: Diabetic auto-
nomic neuropathy (Technical
Review). Diabetes Care.
2003;26:1553–1579
8. Thomas PK: Classification, dif-
ferential diagnosis, and staging
of diabetic peripheral neuropa-
thy. Diabetes. 1997;46 (Suppl.
2):S54– S57
9. Apfel SC, Asbury AK, Bril
V, Burns TM, Campbell JN,
Chalk CH, Dyck PJ, Dyck
PJ, Feldman EL, Fields HL,
Grant IA, Griffin JW, Klein
CJ, Lindblom U, Litchy
WJ, Low PA, Melanson M,
Mendell JR, Merren MD,
O’Brien PC, Rendell M, Rizza
RA, Service FJ, Thomas PK,
Walk D, Wang AK, Wessel
K, Windebank AJ, Ziegler D,
Zochodne DW, Ad Hoc Panel
on Endpoints for Diabetic
Neuropathy Trials. Positive
neuropathic sensory symp-
toms as endpoints in diabetic
neuropathy trials. J Neurol Sci
2001;189:3–5
10. Dyck PJ, Overland CJ, Low
PA, Litchy WJ, Davies JL,
Dyck PJ, O’Brien PC, Cl vs.
NPhys Trial Investigators,
Albers JW, Andersen H, Bolton
CF, England JD, Klein CJ,
Llewelyn JG, Mauermann ML,
Russell JW, Singer W, Smith
AG, Tesfaye S, Vella A. Signs
and symptoms versus nerve
conduction studies to diagnose
diabetic sensorimotor polyneu-
ropathy: CI vs. NPhys trial.
Muscle Nerve 2010;42: 157–164
11. Dyck PJ. Detection, char-
acterization, and staging of
polyneuropathy: assessed
in diabetics. Muscle Nerve
1988;11:21–32
12. Treede RD, Jensen TS,
Campbell JN, Cruccu G,
Dostrovsky JO, Griffin
JW, Hansson P, Hughes
R, Nurmikko T, Serra J.
Neuropathic pain: redefini-
tion and a grading system for
clinical and research purposes.
Neurology 2008;70:1630–1635
13. Boulton AJ, Malik RA, Arezzo
JC, Sosenko JM. Diabetic
somatic neuropathies. Diabetes
Care 2004;27:1458–1486
14. Cruccu G, Anand P, Attal N,
Garcia-Larrea L, Haanpa¨a¨
M, Jørum E, Serra J, Jensen TS.
EFNS guidelines on neuro-
pathic pain assessment. Eur J
Neurol 2004 Mar;11:153–162
15. Vinik EJ, Hayes RP, Oglesby
A, Bastyr E, Barlow P, Ford-
Molvik SL, Vinik AI. The
development and validation of
the Norfolk QOL-DN, a new
measure of patients’ perception
of the effects of diabetes and
diabetic neuropathy. Diabetes
Technol Ther 2005;7:497–508
16. S Jambart, Z Ammache,
F Haddad, A Younes, A
Hassoun, K Abdalla, C ABou
Selwan, N Sunna, D Wajsbrot
and E Yousef. Prevalence of
Painful Diabetic Peripheral
Neuropathy among Patients
with Diabetes Mellitus in the
Middle East Region. J Int Med
Res. 2011;39: 366-377
17 . Tesfaye S. Advances in the
management of diabetic
peripheral neuropathy. Curr
Opin Support Palliat Care
2009;3:136– 143
18. Ziegler D, Nowak H, Kempler
P, Vargha P, Low PA.
Treatment of symptomatic
diabetic polyneuropathy with
the antioxidant alpha-lipoic
acid: a meta-analysis. Diabet
Med 2004;21:114–121
19. Tesfaye S, Watt J, Benbow SJ,
Pang KA, Miles J, MacFarlane
IA. Electrical spinal cord
stimulation for painful diabetic
peripheral neuropathy. Lancet
1996;348:1698–1701
20. Jensen TS, Backonja MM,

Hernández Jiménez S, Tesfaye
S, Valensi P, Ziegler D. New
perspectives on the manage-
ment of diabetic peripheral
neuropathic pain. Diab Vasc
Dis Res 2006;3:108–119
21. McQuay HJ, Tramèr M,
Nye BA, Carroll D, Wiffen
PJ, Moore RA. A systematic
review of antidepressants
in neuropathic pain. Pain
1996;68:217–227
22. Freeman R, Durso-Decruz
E, Emir B. Efficacy, safety,
and tolerability of pregabalin
treatment for painful diabetic
peripheral neuropathy: findings
from seven randomized, con-
trolled trials across a range of
doses. Diabetes Care 2008;31:
1448–1454
23. Lunn MP, Hughes RA, Wiffen
PJ. Duloxetine for treating
painful neuropathy or chronic
pain. Cochrane Database Syst
Rev 2009;7:CD007115
24. Selvarajah D, Gandhi R, Emery
CJ, Tesfaye S. Randomized
placebo-controlled double-blind
clinical trial of cannabis based
medicinal product (Sativex) in
painful diabetic neuropathy:
depression is a major con-
founding factor. Diabetes Care
2010;33:128–130
25. Baron R, Mayoral V, Leijon G,
Binder A, Steigerwald I, Serpell
M. 5% lidocaine medicated
plaster versus pregabalin in
post-herpetic neuralgia and
diabetic polyneuropathy: an
open-label, non-inferiority two-
stage RCT study. Curr Med
Res Opin 2009;25:1663–1676
26. Dan Ziegler , Painful Diabetic
Neuropathy Advantage of
novel drugs over old drugs?
Diabetes Care 2009;32
Supplement 2:S414–S419
27. S Bohlega, T Alsaadi, A Amir,
H Hosny, AM Karawagh,
D Moulin, N Riachi, A Salti
and S Shelbaya . Guidelines
for the Pharmacological
Treatment of Peripheral
Neuropathic Pain: Expert Panel
Recommendations for the
Middle East Region . J Int Med
Res. 2010;38:295-317
28. American Diabetes Association.
Standards of medical care in
diabetes. Diabetes Care
2013;36(Suppl1):S11-66.
29. Haas L, Maryniuk M, Beck J,
Cox CE, Duker P, Edwards
L, Fisher E, Hanson L, Kent
D, Kolb L, McLaughlin S,
Orzeck E, Piette JD, Rhinehart
AS, Rothman R, Sklaroff S,
Tomky D, Youssef G. National
Standards for Diabetes Self-
management Education and
Support. Diabetes Care
2012;35:2393-2401.
30. Boulton AJ, Armstrong
DG, Albert SF, Frykberg
RG, Hellman R, Kirkman
MS, Lavery LA,
Lemaster JW, Mills JL Sr,
Mueller MJ, Sheehan P,
Wukich DK, American
Diabetes Association;
American Association of
Clinical Endocrinologists.
Comprehensive foot exami-
nation and risk assessment.
Diabetes Care 2008;31:1679-85.
31. Apelqvist J, Bakker K, van
Houtum WH, Nabuurs-
Franssen MH, Schaper NC.
International consensus and
practical guidelines on the
management and the preven-
tion of the diabetic foot.
Diabetes Metab. Res. Rev.
2000;16:S84–S92.
32. Dorresteijn JAN, Kriegsman
DMW, Assendelft WJJ, Valk
GD. Patient education for p
preventing diabetic foot ulcer-
ation. Cochrane Database of
Systematic Reviews 2012, Issue
Issue 10. Art. No.: CD001488.
pub4.
33. Solomon Tesfaye, Andrew
J.M. Boulton, Anthony H.
Dickerson, Mechanisms
andManagement of Diabetic
Painful Distal Symmetrical
Polyneuropathy. Diabetes Care
2013;36:2456–2465
CLINICALDIABETESME.ONLINEDIABETES.NET
12 4 2013
2013
Contact Information :
Mailing Address: 3119 Trees of Avalon Parkway,
McDonough , GA 30253
Telephone: 678 759 1561
E-Mail: mahmoud@arab-diabetes.com

Call to Action on Painful Diabetic Neuropathy in Arab World

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Call to Action on Painful Diabetic Neuropathy in Arab World

Similar to Call to Action on Painful Diabetic Neuropathy in Arab World (20)

More from Mahmoud IBRAHIM

More from Mahmoud IBRAHIM (7)

Call to Action on Painful Diabetic Neuropathy in Arab World