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Treatment decisions regarding diabetic neuropathy (DN) can be made based on useful evidence. Many agents have been assessed for therapy of DN pain, and many have some role in relief of symptoms. The opioid tramadol, which has additional (monoamine-related) mechanisms of analgesia, has particular utility in DN. The tricyclic antidepressants (TCAs) are among the most consistently effective therapy for neuropathic pain. Multiple RCTs have demonstrated the efficacy of the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine in the treatment of DN. A withdrawal syndrome can occur if the SNRIs are abruptly discontinued. Anticonvulsants are a valuable therapeutic option in DN. Pregabalin is effective for DN as well. Topical application of local anesthetics may be useful in patients with focal DN pain. Patch application of lidocaine is known to be effective in DN. Intravenously injected local anesthetics have been reported potentially useful in DN.
Analgesia care in geriatric patients requires consideration of several age specific aspects of pain assessment and treatment. Geriatric oligoanalgesia is well known to occur in the acute care setting, and the problem has serious ramifications. Aging changes the physiology of drug absorption, distribution, metabolism, and elimination. Age-associated physiologic changes vary from patient to patient, in both degree and directionality. Opioid therapy provides an illustrative example of how altered elderly pharmacology dictates a conservative approach to analgesia titration. The Beers criteria have been adopted by many healthcare authorities, including the Centers for Medicare and Medicaid Services, and are now the most often-used consensus criteria guiding medication use in older adults. NSAIDs are widely prescribed, and frequently efficacious, in the acute care setting. Opioid selections for moderate (e.g. hydrocodone) or severe (e.g. morphine) pain in the elderly are generally similar to those for younger adults.