Diabetic Lumbosacral Plexopathy Medication
- Author: Divakara Kedlaya, MBBS; Chief Editor: Robert H Meier, III, MD more...
Intravenous human immunoglobulin (IVIg) may hasten recovery in patients with diabetic lumbosacral plexopathy, although this treatment has not yet been proven in controlled studies and remains controversial.[30, 31, 32] Other immunosuppressive agents, such as cyclophosphamide and methylprednisolone, are also thought to improve recovery. Kilfoyle et al studied treatment with pulsed methylprednisolone at 500 mg for 2 days every 2 weeks (instituted within 3 months of symptom onset) and noted significant improvement in pain and weakness in the majority of patients.
Another study, by Dyck et al, suggested that methylprednisolone is effective against diabetic lumbosacral radiculoplexus neuropathy. The double-blind, placebo-controlled study involved 75 patients with the condition, who were randomized to a 12-week regimen of intravenous methylprednisolone or placebo. Although the study’s primary outcome (time to improvement of neuropathy impairment score) was not significantly different between the 2 groups, patients treated with methylprednisolone reported significantly greater symptom improvement, particularly with regard to measures of pain and positive sensory symptoms.
However, a 2009 Cochrane review concluded that no evidence from randomized trials supported a recommendation for immunotherapy’s use in the treatment in diabetic lumbosacral plexopathy. In 2012, an updated Cochrane review reported that supportive evidence was still lacking.
The administration of human immunoglobulins may improve the clinical and immunologic aspects of the disease. Blood products may decrease autoantibody production and increase solubilization and removal of immune complexes.
Immunoglobulin neutralizes circulating myelin antibodies through anti-idiotypic antibodies. In addition, it down-regulates proinflammatory cytokines, including interferon (IFN)-gamma; blocks Fc receptors on macrophages; suppresses inducer T-cells and B-cells and augments suppressor T-cells; blocks complement cascade; promotes remyelination; and may increase cerebrospinal fluid (CSF) levels of immunoglobulin (Ig) G (10%).
Immunosuppressive agents such as cyclophosphamide, methylprednisolone, and prednisone may improve recovery.
Cyclophosphamide is a cyclic polypeptide that suppresses some humoral activity. It is chemically related to nitrogen mustards and is activated in the liver to its active metabolite, 4-hydroxycyclophosphamide, which alkylates the target sites in susceptible cells in an all-or-none–type reaction. When used in autoimmune diseases, the mechanism of action is thought to involve immunosuppression due to destruction of immune cells via DNA cross-linking.
Azathioprine is an imidazolyl derivative of 6-mercaptopurine. It antagonizes purine metabolism and inhibits synthesis of DNA, RNA, and proteins. It works primarily on T cells and suppresses hypersensitivities of the cell-mediated type and causes variable alterations in antibody production.
Methylprednisolone is an immunosuppressant that decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Prednisone is an immunosuppressant that can be used for the treatment of autoimmune disorders. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear activity. It stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
These drugs have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.
Amitriptyline is an oral analgesic for certain types of chronic pain. The usual adult dose ranges from 30-150 mg/d.
Nortriptyline has demonstrated effectiveness in the treatment of chronic pain via inhibition of the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane. As a result, this drug increases the synaptic concentration of these neurotransmitters in the central nervous system (CNS). In addition, pharmacodynamic effects, such as the desensitization of adenyl cyclase and the down-regulation of beta-adrenergic receptors and serotonin receptors, appear to play a role in its mechanisms of action.
This agent inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Desipramine may increase the synaptic concentration of norepinephrine in the CNS by inhibiting reuptake by presynaptic neuronal membrane. The drug may have effects in the desensitization of adenyl cyclase and in the downregulation of beta-adrenergic receptors and serotonin receptors.
These agents are used for neuropathic pain.
Gabapentin has anticonvulsant properties and antineuralgic effects; however, its exact mechanism of action is unknown. The drug is structurally related to gamma-aminobutyric acid (GABA) but does not interact with GABA receptors. Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).
Pregabalin is a structural derivative of GABA. The mechanism of action is unknown. It binds with high affinity to the alpha2-delta site (a calcium channel subunit). It is FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
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