Providers caring for patients with painful diabetic neuropathic should be educated on the benefits of neuromodulation for eligible candidates, according to research results published in Frontiers in Pain Research.

In the current study, researchers sought to explore the referral patterns in patients with painful diabetic neuropathy in order to determine utilization of neuromodulation as a treatment for neuropathic pain. Investigators compared cohorts who received no treatment, conservative treatment, and neuromodulation treatment based on diagnoses, referrals, therapeutic strategies, and/or demographic information.

Patients at a single tertiary care center who saw providers in endocrinology, neurology, and/or neurosurgery between 2019 and 2020 were identified via billing codes. Patient notes were manually examined to verify painful neuropathy diagnosis. Charts were reviewed for the use of conservative treatment or CPT codes for neuromodulation therapy.


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In the first year, 2746 patients with type 1 or 2 diabetes were treated for neuralgia or neuropathic pain, neuropathy, chronic pain, limb pain, or diabetic neuropathy. After exclusion criteria were applied, the total dataset included 2635 patients for analysis. These patients were separated into 3 cohorts based on treatment: no treatment (n=700), conservative/pharmacologic treatment (n=1906), and neuromodulation treatment (n=29). Cohorts were compared based on sex, age, diabetes status, patient provider visits, and pain medication use.

Those with untreated painful diabetic neuropathy were more likely to be older vs those on conservative management (65.11±0.50 years vs 63.08±0.29 years) and more likely to be men (59.71% vs 51.73%). Age differed between the no treatment and conservative treatment groups, but was not statistically significant.

Patients who were prescribed 3 or more pain medications were more likely to be women and slightly younger (61.51±0.43 years vs 64.18±0.38 years for those receiving 0-2 medications). In the no treatment group, 93% of patients had a type 2 diabetes diagnosis compared with 89.4% of those in the conservative management group.

Significant differences in each treatment cohort were noted based on visits to general neurology, neurology pain, and anesthesia pain. Compared with no treatment patients, those with conservative treatment more frequently saw endocrinology, neurology, anesthesia pain, and neurosurgery providers. In the neuromodulation group, 24 patients saw a general neurologist, 6 saw a pain neurologist, and 3 saw anesthesia pain specialists.

Patients were further divided into 2 groups: those prescribed between 1 and 2 medications and those prescribed 3 or more medications. In the conservative management cohort, 59.03% of patients were prescribed between 1 and 2 medications, compared with 40.97% taking 3 or more medications. Of the patients referred for neuromodulation, 14 of 29 were taking 3 or more medications. As a whole, the cohort average 2.78 pain medications.

Neuromodulation patients who saw endocrinologists, neurosurgeons, and neurologists were often followed by additional specialties (10.3%, 17.2%, and 48.3%, respectively). Those managed conservatively had lower percentages (17.9%, 6.8%, and 13.7%). Very few patients in the no treatment group were followed by multiple specialties.

Study limitations include the observational nature of the research, the short time period, and the small number of patients in the neuromodulation cohort.

“These results warrant education of providers regarding the potential benefits of neuromodulation procedures,” the researchers concluded.

Reference

Olmstead ZT, Hadanny A, Marchese AM, et al. Recommendations for neuromodulation in diabetic neuropathic pain. Front Pain Res. Published online September 7, 2021. doi:10.3389/fpain.2021.736308