Pharmacological Reports

Copyright 2013

2013, 65, 16011610

by Institute of Pharmacology

ISSN 1734-1140

Polish Academy of Sciences

Review

Mechanisms and pharmacology of diabetic

neuropathy experimental and clinical studies
Magdalena Zychowska, Ewelina Rojewska, Barbara Przewlocka,
Joanna Mika
Department of Pain Pharmacology, Institute of Pharmacology, Polish Academy of Sciences, Smtna 12,
PL 31-343 Krakw, Poland
Correspondence: Joanna

Mika, e-mail: [email protected]

Abstract:
Neuropathic pain is the most common chronic complication of diabetes mellitus. The mechanisms involved in the development of
diabetic neuropathy include changes in the blood vessels that supply the peripheral nerves; metabolic disorders, such as the enhanced
activation of the polyol pathway; myo-inositol depletion; and increased non-enzymatic glycation. Currently, much attention is focused on the changes in the interactions between the nervous system and the immune system that occur in parallel with glial cell activation; these interactions may also be responsible for the development of neuropathic pain accompanying diabetes. Animal models
of diabetic peripheral neuropathy have been utilized to better understand the phenomenon of neuropathic pain in individuals with
diabetes and to define therapeutic goals. The studies on the effects of antidepressants on diabetic neuropathic pain in streptozotocin
(STZ)-induced type 1 diabetes have been conducted. In experimental models of diabetic neuropathy, the most effective antidepressants are tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors. Clinical
studies of diabetic neuropathy indicate that the first line treatment should be tricyclic antidepressants, which are followed by anticonvulsants and then opioids. In this review, we will discuss the mechanisms of the development of diabetic neuropathy and the most
common drugs used in experimental and clinical studies.
Key words:
neuropathic pain, diabetic neuropathy, therapy, antidepressants, anticonvulsants, opioids, neuroimmune interactions

Introduction
The World Health Organization estimates that the
global prevalence of diabetes is currently approaching
5%; thus, this disease can be called an epidemic of the
21st century. Diabetes is considered a major cause of
mortality and morbidity [56], and statistically, diabetic
neuropathy is the second most common cause of posttraumatic nerve damage [23]. Therefore, clinical reality
suggests the need for the effective treatment of neuropathic pain accompanying diabetes. There are three

main types of diabetes: insulin-dependent diabetes

mellitus (type 1), non-insulin-dependent diabetes mellitus (type 2) and gestational diabetes. Diabetes mellitus is a group of metabolic diseases characterized by
high blood glucose concentration, frequent urination,
and increased thirst and hunger. Thus, diabetes is one
of the leading causes of neuropathy worldwide. Diabetic neuropathy is not always painful, however, 12%
of all diabetic patients are affected with symptomatic
painful diabetic neuropathy [44], the most common
chronic and earliest occurring complication. Diabetic
neuropathy affects all peripheral nerves including pain
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fibres, motor neurons and the autonomic nervous system [44]. The pathogenesis of diabetic neuropathy is
complicated, and the mechanism of this disease remains poorly understood. It has been suggested that
hyperglycemia is responsible for changes in the nerve
tissue [56]. There are two main suppositions of this
proposed mechanism: vascular and metabolic [10]. The
current hypothesis suggests that neuroimmune interactions actively contribute to the onset and persistence of
pain in diabetes [3]. In addition, the participation of
glial cells in the processes accompanying the development of diabetic neuropathic pain has been recently investigated [41]. Therefore, to better understand the
mechanisms underlying the development of painful
diabetic neuropathy, animal models of diabetes type 1
and diabetes type 2 have been used to explore this disease entity [60].
The drugs currently used for the treatment of diabetic neuropathic pain include antidepressants, such
as tricyclic antidepressants or duloxetin [4]; anticonvulsants, such as pregabalin [12]; and typical analgesics, such as tapentadol [45], and these may be used
individually or in combination [25, 67]. However,
knowledge concerning the pathogenesis of diabetic
neuropathic pain is not sufficient to propose an efficient therapy for the long-lasting reduction of pain
symptoms and increase the satisfaction of diabetic patients. The use of typical painkillers is not satisfactory
in alleviating neuropathic pain, further supporting attempts to develop improved pain-relieving methods.
Therefore, in this review, we will discuss the putative mechanisms for the development of diabetic neuropathy and the involvement of glial cells in this process based on observations from in vivo models. We
will also describe studies of the most frequently used
drugs for the relief of diabetic neuropathic pain in the
clinic and in animal diabetic neuropathic pain models.

Mechanisms of diabetic neuropathy

development
The pathological mechanisms implicated in diabetic
neuropathy, include microvascular damage, metabolic
disorders, and changes in the interactions between
neuronal and immunological systems in parallel with
glial cell activation [14, 35, 42].

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Changes in the blood vessels supplying the peripheral nerves underlie the mechanisms involved in
microvascular damage and hypoxia. These changes
are based on increases in wall thickness with the hyalinization of the vessel walls and the basal lamina of
arterioles and capillaries, leading to nerve ischemia
[42]. Through revised primary capillary membrane to
the endoneurium penetrates the plasma protein, causing swelling and increased interstitial pressure in the
nerves as well as capillary pressure, fibrin deposition
and thrombus formation [10]. Pathological studies of
the proximal and distal segments of the nerve have
shown multifocal fibre loss along the length of the
nerves, suggesting ischemia as a pathogenetic contributor [15].
Metabolic disorders are the primary cause of diabetic neuropathy. A hyperglycemic state accompanying diabetes type 1, which is induced through decreased insulin secretion, is responsible for the enhanced activation of the polyol pathway (Fig. 1). In
the hyperglycemic state, the affinity of aldose reductase for glucose is increased, leading to the increased
production of sorbitol. Sorbitol does not cross cell
membranes and accumulates intracellularly in the
nervous tissue, thus generating osmotic stress. Osmotic stress increases the intracellular fluid molarity
as well as water influx, Schwann cell damage and
nerve fibre degeneration [38]. Furthermore, upregulation of the NADPH oxidase complex results in
oxidative stress through reduced glutathione production, decreased nitric oxide concentrations and increased reactive oxygen species concentrations
(Fig. 1) [31]. Free radicals, oxidants, and some unidentified metabolic factors activate the nuclear enzyme poly(ADP-ribose) polymerase (PARP), which is
a fundamental mechanism in the development of diabetic complications, including neuropathy [14].
Moreover, a nitric oxide deficit and increased oxygen
free radical activity are responsible for microvascular
damage and hypoxia [35].
Myo-inositol depletion also causes diabetic neuropathy. Excess sorbitol accumulates in nervous tissue,
which leads to and causes osmotic stress and tissue
damage. Simultaneously, decreases in the concentration of myo-inositol reduce ATP-ase Na+/K+ activity,
which is important in impulse conduction. Under normal conditions, the myo-inositol content is approximately 30-fold higher in peripheral nerves than in
plasma [8]. In the nerve, 20% of the myo-inositol is
bound to phosphoinositides, which are associated with

Diabetic neuropathy
Magdalena Zychowska et al.

Fig. 1.

Multifactorial

etiology

of dia-

betic neuropathy. Hyperglycemia leads

to enhanced activation of the polyol
pathway,

oxidative

stress

and

non-

enzymatic glycation. These factors either interact or independently function

toward

the

development

of

diabetic

neuropathy, directly affecting nerve tissues or nutrient vascular tissues [31,

38, 52, 54]

cell membrane phospholipids. The remaining pool of

myo-inositol in the nerves is present in a free/unbound
form. Phosphoinositides are metabolically active cell
phospholipids associated with the cell membrane. The
phosphatidylinositol cycle involves the transformation
of phospholipids accompanied by cell activation, and
this cycle is important for the conduction of nerve impulses [16]. Under normal conditions, the Na+/K+
ATP-ase activity in the nerve maintains a lower concentration of sodium in the peripheral nerves compared
to the plasma [27]. In diabetes, myo-inositol deficiency
is observed in the nerves, resulting from the inhibition
of the sodium-dependent uptake of myo-inositol and
severe changes to the polyol pathway. The reduced
myo-inositol concentration causes the insufficiency of
renal ATP-ase Na+/K+, the enzyme necessary to generate nerve depolarization (Fig. 1). As a result, the conduction of stimuli is reduced [10, 52]. Sundkvist et al.
showed that high myo-inositol levels are associated
with nerve regeneration, despite the low levels of this
polyol observed in diabetic patients in the clinic.
Therefore, the elevation of myo-inositol levels might
be considered a compensatory mechanism to prevent
nerve damage [51].
Increased non-enzymatic glycation/glycoxidation
(glycation processes involving oxidation) of proteins
also plays an important role in the development of
diabetic neuropathy (Fig. 1) [54]. In a hyperglycemic
state, the increased levels of glucose and fructose result in covalent binding of these sugars to proteins,

nucleotides or lipid molecules without control by an

enzyme. This process applies to the structural proteins
of the nerve and the blood vessels supplying these
nerves, and the products of these transformations, advanced glycation products (AGE), alter cellular functions. AGEs cause a number of disorders, including
focal thrombus formation and vasoconstriction, and
affect cellular DNA. Furthermore, protein glycation
might decrease cytoskeletal assembly, induce protein
aggregation, and provide ligands for cell surface receptors [54]. AGE microcirculation leads to changes
in the vessels resulting from prior hyperglycemic conditions, as the level of AGEs is not decreased by normoglycemia. Furthermore, AGEs have been implicated in the formation of free radicals. The induction
of the non-enzymatic glycation structural proteins of
nerve fibres leads to excessive rigidity and impaired
axonal transport [5] because tubulin glycation leads to
the inhibition of GTP-dependent tubulin polymerization [62]. AGEs have been identified not only in myelinated and unmyelinated fibres but also in the perineurium, endothelial cells, and pericytes of endoneurial microvessels. Moreover, the receptors for
advanced glycation (RAGE) and glycation products
are expressed in peripheral neurons [54]. Interactions
between macrophages and AGE-myelin might also
influence or contribute to the segmental demyelination associated with diabetic neuropathy [57].
A growing body of evidence indicates that the activation of non-neuronal cells (microglia, astrocytes
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IMMUNOLOGICAL CELLS
ACTIVATION

STREPTOZOTOCIN INJECTION

DAMAGE OF b-CELLS

Fig. 2.

INCREASE IN
TNFa RELEASE
HYPERGLYCEMIA

DECREASE INSULIN PRODUCTION

of

proposed

diagram

of

the

streptozotocin-induced

peripheral

neuropathic pain [3, 49, 68]

RELEASE MMP-9
BY NEURONS

NERVE DAMAGE

DEREGULATION
OF SYGNALING PATHWAYS
NFkB, AP-1

cytokine network in the pathogenesis

INCREASE IN IL-1b
RELEASE IN DRG

CYTOKINES
INCREASE IN CCL2, CCL5,
MMP-9 RELEASE

MICROGLIA ACTIVATION

CX3CR1
CCR2

NEUROPATHIC PAIN

p-p38 MAPK

CCR5

RELEASE OF IL-1b
AND OTHER IMMUNOLOGICAL
FACTORS LIKE TNF a

and immune cells) plays an important role in the development of neuropathic pain [34], and these cells
are activated under hyperglycemic conditions in the
spinal cord [11, 55]. Studies have shown that glia
strongly influence the synaptic communication between neurons, leading to pathological pain [58]. Several studies have shown that in the spinal cord, activated microglia play a crucial role in neuropathic pain
through the release of proinflammatory cytokines,
which are common mediators of allodynia and hyperalgesia (Fig. 2) [34, 58]. Recent reports suggest the
involvement of proinflammatory factors derived from
activated microglia in diabetes-induced allodynia [55,
68] and the involvement of the p38 MAPK pathway
in dorsal horn microglia in diabetes-induced hyperalgesia [11]. There are many reports implicating the release of pro-inflammatory cytokines from glia and
immune cells as a pathomechanism for neuropathic
pain of different origins. In rats, painful neuropathy
accompanies type 1 diabetes and is associated with
the release of pro-inflammatory cytokines, such as
IL-1b, IL-6 and TNFa [3], while a decrease in insulin
production causes the increased release of metalloproteinase MMP-9 and monocyte chemotactic protein-1
(MCP-1) [49]. Active glial cells, particularly microglia, which are resident macrophages of the central
nervous system, are responsible for signalling between components of the nervous and immune systems. Pabreja et al. [41] showed that microglia might
be responsible for the initiation of neuropathic pain
states. Similar results in rat models of diabetic neuropathy have demonstrated that the pre-emptive administration of minocycline attenuates the development of
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pain that is associated with decreased levels of IL-1b

and TNFa. These results support the hypothesis that
spinal microglia become activated under hyperglycemic conditions, leading to the elevation of proinflammatory cytokines and oxidative stress. Moreover,
Bishnoi et al. observed significantly increased levels
of proinflammatory cytokines (IL-1b, IL-6, and
TNFa) in the spinal cord in a rat model of diabetes induced through streptozotocin (STZ) administration
[3]. Thus, the initiation of the pain process during diabetic neuropathy is mediated through proinflammatory cytokines, such as TNFa, IL-1b, IL-2, and IL-6,
that are released from activated microglia.
The determination of the role of numerous immune
factors released during diabetic neuropathy from
nerve and immune cells will broaden our understanding of the underlying pathomechanisms. For this reason, it is important to understand how glial cell activation products, particularly those released from microglia, influence the development of neuropathic
pain in diabetic neuropathy and whether the inhibition
of glia activation affects the release of pro- and antiinflammatory cytokines, thus reducing pain.

Diabetic neuropathy experimental

studies
Animal models of diabetic neuropathy

Diabetic peripheral neuropathy is one of the most

common consequences of diabetes and might be associated with diabetes type 1 and type 2. The mecha-

Diabetic neuropathy
Magdalena Zychowska et al.

Tab. 1. Experimental rodent models of diabetic neuropathic pain [60]

TYPE 1

Pharmacology of experimental diabetic

neuropathy

Spontaneous-induced diabetes
Type 1 diabetic insulinopenic BB/Worchester Rats
NOD Mice
LETL Rats
Akita Mice spontaneous type 1 diabetes
Chemo-induced pancreatic toxicity
Streptozotocin-induced diabetes
Alloxan-induced diabetes
TYPE 2
Spontaneous-induced diabetes
Type 2 diabetic hyperinsulinemic BBZDR / Worchester Rats
Tsumura Suzuki Obese Diabetes (TSOD) mice
Otsuka Long-Evans Tokushima Fatty (OLETF)
Dietary-induced diabetes
High-fat diet-fed mice
Genetic-induced diabetes
Zucker diabetic fatty rat
Obese leptin-deficient (ob/ob) mice
Leptin receptor-deficient (db/db) mice
Nonobese diabetic mice Goto-Kakizaki strain
Stress-induced diabetes
Streptozotocin/high fat diet model of type 2 diabetes

nism of this neurological impairment remains unknown, and the proposed therapies are inefficient.
Animal models of diabetic peripheral neuropathy provide a better opportunity to study this phenomenon
and determine therapeutic goals. In 2012, Wattiez et
al. [60] demonstrated that it is possible to study diabetes using experimental diabetic models of neuropathic
pain from both type 1 and 2 (Tab. 1). A PubMed
search using the keywords diabetic neuropathy
yields 20,350 results published between 1945 and
2013, whereas a search with diabetic neuropathy in
animal model yields 1,865 results published between
1964 and 2013. The development of good models to
study this phenomenon facilitates the characterization
of the pathology of these diseases and the identification of molecular targets, parallel with pharmacological strategies for improving clinical care.

Antidepressants

We have identified a number of studies on the role of

antidepressants in STZ-induced diabetes type 1, but information concerning the potential influence of antidepressants in other animal models of diabetic neuropathic pain, as shown in Table 1, is still lacking. The
best studied antidepressants in animal models of diabetic neuropathy are tricyclic antidepressants, which
are first line therapies for the clinical treatment of diabetic neuropathic pain. Many studies have demonstrated the antiallodynic and antihyperalgesic effects of
amitriptyline, the most common antidepressant tested
in the STZ-induced diabetic neuropathic pain model.
Using an STZ pain model, Yamamoto et al. showed
that a single oral administration of amitriptyline was
ineffective in diminishing allodynia in the early phase
of diabetes; however, amitriptyline treatment was effective when the disease was fully developed [66].
Thus, many studies have shown contradictory results
concerning the administration of amitriptyline and the
extent of diabetes. For example, the acute intraperitoneal administration of amitriptyline in diabetic rats also
exhibited major effects on thermal allodynia and mechanical hyperalgesia [2]. However, the results of other
studies have suggested that amitriptyline does not attenuate mechanical allodynia, even after chronic administration [28]. Treatment with clomipramine and
desipramine induces weak analgesia in STZ-induced
diabetic hyperalgesia [9]. Other classical TCAs (imipramine, doxepin, and nortriptyline) or TeCAs (amoxapine and maprotiline) have not been tested in an animal
model of diabetic neuropathy.
Currently, a large number of studies have been focused on the role of SSRIs and SNRIs in STZ-induced
diabetic neuropathy. Some results have shown that
fluoxetine (SSRI) attenuates thermal hyperalgesia in
mice [1]. Tembhurne and Sakarkar demonstrated that
chronic treatment (9 weeks) with fluoxetine reduces
pain perception in rats [53]. In contrast, Sounvoravong et al. demonstrated that fluoxetine alone shows
no effect in the von Frey and tail-pinch tests, but the
co-administration of this compound with morphine
significantly enhanced its antinociceptive and antiallodynic effects in mice [50]. The SSRIs fluvoxamine
and paroxetine exhibit antiallodynic effects in the rats
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[22]. These authors also showed that the intrathecal

administration of milnacipran (SNRI) produced antiallodynic effects in a dose-dependent manner [22]. In
our studies, using a single injection of milnacipran in
mice 7 days after STZ administration, a slight decrease in neuropathic pain syndromes, such as allodynia and hyperalgesia, was observed. Other researchers have demonstrated that chronic intraperitoneal injection with milnacipran and duloxetine
reduced mechanical hyperalgesia in diabetic rats [59].
This result has been associated with increasing levels
of adenosine, suggesting the involvement of the
adenosinergic pathway in the antinociceptive effect of
duloxetine [26]. Other studies have also shown that
the systemic and spinal, but not peripheral, administration of duloxetine alleviates tactile allodynia in
rats [36]. Another SNRI, venlafaxine, exhibited significant effects on thermal allodynia and mechanical
hyperalgesia in rat diabetic neuropathic pain models
[2]. Venlafaxine also increased the analgesic activity
of morphine with acute co-administration, but in
chronic treatment, this compound attenuated opioid
efficacy in STZ-induced hyperalgesia [6].
There are other antidepressants that have not been
tested in animal models of diabetic neuropathy, including the SSRI escitalopram; the SNRI desvenlafaxine;
MAOIs, such as harmaline, iproclozide, iproniazid,
isocarboxazid, toloxatone, tranylcypromine, nialamide,
and moclobemide; and atypical antidepressants, such
as bupropion, trazodone, mirtazapine and nefazodone.
Anticonvulsants

Anticonvulsants have also been studied for treatment

of diabetic neuropathy. Anticonvulsants can be divided into three groups. The first group includes CaV
channel a2d subunit ligands, such as pregabalin and
gabapentin. The antiallodynic and analgesic effects of
these drugs involve ligand binding to the a2d-1
subunit of the CaV2.X. Martinez et al. showed that
pregabalin relieves mechanical allodynia and thermal
hyperalgesia in a rat STZ-induced diabetic pain
model. Furthermore, the effect of pregabalin was limited by the suppression of CaVa2d-1 expression in
the spinal dorsal horn under conditions of neuropathic
pain [30]. Gabapentin not only attenuated mechanical
allodynia but also reduced microglia activation in
a rat STZ-induced diabetic neuropathy model [64].
A second type of blockers includes the N-type CaV
channels (CaV2.2) leconotide and ziconotide, which
have shown dose-dependent analgesic activity after
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intravenous administration in a diabetic neuropathic

pain model [24].
The dose-dependent reduction of mechanical allodynia through treatment with the sodium channel
blockers lidocaine and mexiletine was demonstrated
in a rat STZ model of diabetic neuropathy [33, 66].
Moreover, Mert and Gunes [33] showed that antinociceptive effects from A803467, a highly selective
blocker of Nav1.8 channels, are observed in diabetic
rats with painful neuropathy. Studies on primary sensory neurons have demonstrated that a number of antidepressants, including the tricyclic antidepressants
amitriptyline, nortriptyline, imipramine, desipramine,
and maprotiline, evoke effects through sodium channel blocking, thereby contributing to the antihyperalgesic efficacy of these compounds [13].
Opioids

Although there is a large consensus on effectiveness of

opioid drugs in nociceptive pain, the efficacy of these
compounds in neuropathic pain has, until recently,
been a matter of debate. Nielsen et al. [37] showed hyporesponsiveness to morphine in STZ-diabetic rats
with long-term diabetes, however, in STZ-diabetic
mice tapentadol was more effective than morphine in
attenuating heat hyperalgesia, but both opioids reduce
heat-induced nociception in dose-dependent manner
[7]. In STZ-induced diabetic models, the decreased
antiallodynic effect of morphine has been associated
with a decrease in the release of specific endogenous
opioids and impaired G-protein coupling to -opioid
receptors [61]. The influence of the modulation of glial
activity on the analgesic effects of morphine in neuropathic pain has been recently studied [34]. Our recent
data suggested that the activation of microglial cells
enhanced proinflammatory cytokine expression in the
spinal cord, and changes in neuroimmune interactions
are involved in the development of morphine tolerance
in diabetic neuropathy [68].

Diabetic neuropathy clinical studies

Types of diabetic neuropathy

There are no neurophysiological or morphological differences between patients with type 1 and type 2 diabe-

Diabetic neuropathy
Magdalena Zychowska et al.

tes nor between diabetic patients with and without

painful neuropathy [29]. Some people with diabetes
have nerve damage without signs, others over time,
may have symptoms such as tingling, numbness, loss
of feeling or pain. Nerve problems can occur in every
organ system, and therefore, diabetic neuropathy can
be classified as peripheral, autonomic, proximal, or focal. The most common type of diabetic neuropathy is
peripheral neuropathy, which causes pain or loss of
feeling in the toes, feet, legs, hands, and arms. The
autonomic neuropathy causes changes in digestion,
bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the
heart and control blood pressure, as well as nerves in
the lungs and eyes. The proximal neuropathy causes
pain in the thighs, hips, or buttocks and leads to weakness in the legs. The focal neuropathy results in the
sudden weakness of one nerve or a group of nerves,
causing muscle weakness or pain [65].
Pharmacology of diabetic neuropathy

Diabetic neuropathic pain treatment is difficult because no specific relief medication is available. The
American Diabetes Association recommends the use
of tricyclic antidepressants, followed by anticonvulsants and opioids, such as tapentadol or oxycodone. In
addition, maintenance of blood sugar levels within
a narrow target range might delay the progression of
peripheral neuropathy.
Antidepressants

Tricyclic antidepressants (TCAs) have been shown to

be effective for symptomatic pain relief in diabetic
neuropathy and are used in 40% of cases [4, 21, 32,
47]. TCAs inhibit norepinephrine and/or serotonin reuptake within the central nervous system. Thus,
TCAs, such as amitriptyline, nortriptyline, desipramine and imipramine, might provide relief for
mild to moderate symptoms of pain, but these compounds might also cause a number of side effects, including dry mouth, sweating, sedation and dizziness.
Max et al. [32] showed that amitriptyline is effective
in alleviating the pain resulting from diabetic neuropathy, and the efficacy of this compound has also
been confirmed in other studies [4]. Other TCAs, such
as imipramine and desipramine, have demonstrated
effectiveness in reducing the pain associated with diabetes [47]. Desipramine relieves diabetic neuropathy

pain with an efficacy similar to that of amitriptyline

[32]. Combined treatment with nortriptyline and
fluphenazine has produced a significant reduction of
pain in patients with diabetic polyneuropathy [18].
There are no available data concerning the clinical use
of doxepin or tetracyclic antidepressants (TeCAs),
such as amoxapine and maprotiline, which also relieve diabetic neuropathic pain.
Some antidepressants from the selective serotonin
reuptake inhibitor (SSRI) family have also been used
to treat diabetic neuropathy. Although Max et al. [32]
showed that fluoxetine is not effective in patients with
diabetic neuropathy, but the significant analgesic effects of other SSRIs, such as citalopram and paroxetine, have been recently demonstrated in two minor
trials (20 and 15 patients) [48]. Otto et al. [40] showed
that escitalopram was effective in 41 patients with
painful diabetic neuropathy. The use of fluvoxamine
to relieve the pain associated with diabetic neuropathy
has been demonstrated in a single case concerning
a 48-year-old man with a 14-year history of type 2
diabetes [39].
The serotonin and norepinephrine reuptake inhibitors (SNRIs) are also used in the clinic, despite their
adverse effects. The antidepressant duloxetine is effective in relieving the pain associated with diabetic
neuropathy, and there was no significant difference in
analgesic efficacy between amitriptyline and duloxetine [4]. Rowbotham et al. [43] showed that venlafaxine moderately reduced pain in patients with painful
diabetic neuropathy. Furthermore, patients with diabetic neuropathy who have not responded to gabapentin experienced pain relief upon the addition of venlafaxine, as the combination was moderately effective
[46]. There is no information concerning the potential
analgesic effects of other SNRIs, such as desvenlafaxine or milnacipran, in diabetic neuropathy in the
clinic, although experimental studies have revealed
positive effects (discussed in the next chapter).
Monoamine oxidase inhibitors (MAOIs), including
harmaline, iproclozide, iproniazid, isocarboxazid,
toloxatone, tranylcypromine, nialamide and moclobemide, have not been tested in clinical trials for any type
of neuropathic pain, including diabetic neuropathy.
Some research studies have focused on the role of
atypical antidepressants in reducing painful diabetic
neuropathy syndromes. Wilson [63] examined 31
adult diabetic patients with painful distal polyneuropathy and showed that low doses of trazodone (50
100 mg/day) are effective treatment option. Nefazo-

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done was effective in ameliorating the pain, paresthesias, and numbness associated with diabetic neuropathy [19]. Other atypical antidepressants, such as mirtazapine and bupropion, have not been examined in
clinical trials for the treatment of diabetic neuropathy;
however, there is some experimental evidence supporting the use of these compounds.
Anticonvulsants

cations used to reduce neuropathic pain syndromes

during diabetes are not sufficient. Therefore, an increased understanding of neuroimmune interactions
might provide new possibilities for the development
of innovative therapies, particularly polytherapies,
which can be successfully used in the clinic.

Acknowledgments:
This study was financed from statutory funds, grant NCN
no. 2012/05/N/NZ4/02416 and grant Demeter-1.1.2.5.4

Drugs such as gabapentin and pregabalin, which are

typically used to treat seizure disorders, have also
been prescribed for diabetic neuropathic pain and are
used in 25% of cases [21]. Studies [12, 25, 67] have
shown that monotherapy with gabapentin or pregabalin produces clinically and subjectively meaningful
pain relief in patients with painful diabetic neuropathy. Moreover, the co-administration of gabapentin
with morphine and oxycodone results in improved analgesic effects at lower doses than treatment with either drug alone [17, 20]. Zin et al. [67] showed that
pregabalin did not enhance the effectiveness of oxycodone in diabetic neuropathy.
Opioids

Opioid analgesics, such as tapentadol [45], oxycodone [20] or morphine [17] might also be used to relieve diabetic neuropathic pain, however, are used
alone only in 7% of cases [21].

Summary
Diabetic neuropathic pain treatment is difficult because no specific relief medications are available, and
the pathomechanism of diabetic neuropathic pain development is multidirectional and complicated. Many
animal models of diabetes have been developed to
better understand this disease, and more studies are
needed to examine the potential role of antidepressants in diabetes treatment, as only the STZ-model
has been well studied. As shown in this review, the
mechanisms of the pathogenesis implicated in diabetic neuropathy include microvascular damage,
metabolic disorders, and changes in the interaction
between the neuronal and immunological systems associated with glial cell activation. The current medi-

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no. POIG.01.01.02-12-004/09.

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Received: July 15, 2013; in the revised form: October

accepted: October 21, 2013.

15, 2013;