DADE CE Program 1: Case 2

Program 1: Don't Start: Growing Evidence Against Anticholinergic Drug Use in the Elderly:
Case 2

AL is a 79-year-old man suffering from poorly controlled Type II diabetes diagnosed seven years ago. At today's office visit, he complains of a painful, burning sensation in his toes and feet. When questioned, AL notes that the burning or tingling sensation has been present for about 6 weeks and seems to be worsening over time. His physical exam and clinical history are consistent with painful diabetic neuropathy.

When considering drug therapy for neuropathic pain in this elderly patient, it is important to consider:

Treatment of neuropathic pain can be difficult. This type of pain often responds poorly to NSAIDs and opiates. Antidepressants and anticonvulsants have shown promise for the management of neuropathic pain. Tricyclic antidepressants (TCAs) are considered a mainstay of therapy for painful neuropathies. The best evidence available is for amitriptyline.
For older patients, amitriptyline is often difficult to tolerate due to anticholinergic side effects. In fact, amitriptyline use is considered potentially inappropriate in the elderly. Epidemiologic evidence suggests that approximately 40% of seniors with painful neuropathies receiving TCAs have concurrent health conditions (primarily cardiovascular in nature) that increase their risk of adverse drug events. If a TCA is necessary for this patient, consider nortriptyline, which is the least anticholinergic of the TCAs and is better tolerated in the elderly.
Alternatives to amitriptyline for the management of neuropathic pain include pregabalin, duloxetine, and SSRIs. Doses should start low in elderly patients and be increased as needed and tolerated.
To prevent further complications in this patient it is important to protect the distal extremities by ensuring that shoes fit properly and good skin care is employed. Better glycemic control is also essential.

References:

Berger A, Dukes EM, Edelsberg J, et al. Use of tricyclic antidepressants in older patients with painful neuropathies. Eur J Clin Pharmacol 2006;62:757-764.

Cayley WE. Cochrane for Clinicians: Antidepressants for the treatment of neuropathic pain. Am Fam Physician 2006;73:1933-4.

Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips: 2005, 7th edition. New York: The American Geriatrics Society; 2005.