Cost and effect: Cheaper remedies should rule for diabetes nerve pain, U-M experts say

November 05, 2014

ANN ARBOR, Mich. -- Millions of people with diabetes take medicine to ease the shooting, burning nerve pain that their disease can cause. And new research suggests that no matter which medicine their doctor prescribes, they'll get relief.

But some of those medicines cost nearly 10 times as much as others, apparently with no major differences in how well they ease pain, say a pair of University of Michigan Medical School experts in a new commentary in the Annals of Internal Medicine.

That makes cost -- not effect -- a crucial factor in deciding which medicine to choose for diabetic neuropathy, or diabetes nerve pain, the U-M researchers say.

Their commentary accompanies a paper from Mayo Clinic researchers and their colleagues, who analyzed a wide range of data from clinical trials of different treatments for painful diabetic neuropathy. The Mayo-led team concluded that several options appear to work well, though they need to be compared head-to-head to tell for sure which is best.

Until new studies can make those head-to-head comparisons, say the U-M experts, doctors should consider the cost of the drug, and any other conditions a patient has, when deciding what to prescribe.

Brian Callaghan, M.D., the article's first author, says the new Mayo study, national guidelines and other efforts have focused on how well different treatments work against diabetic nerve pain. Half of all people with diabetes develop neuropathy sometime during their experience with the disease, and it can keep patients from exercising or walking. Neuropathy plays a role in many diabetes complications.

But cost hasn't figured into these studies, he says. That's why he and fellow U-M neurologist Eva Feldman, M.D., Ph.D., decided to look at the dollars side of diabetic neuropathy for their article.

"These treatments all work about the same, but what's different is their side effects and cost. The older medications are an order of magnitude cheaper, about $15 to $20 a month, compared with the newer ones at nearly $200 per month," he says. "Patients are on these medications for many years, and it really starts to add up. Given that the effects of the medications are similar, why should we start patients on the expensive drugs until we've determined whether or not they respond to the less-expensive ones?"

The newer drugs, of course, have marketing campaigns behind them - and in the case of diabetic neuropathy, their manufacturers may have sought and received specific approval for diabetic neuropathy from the Food and Drug Administration.

The newer drugs have earned the highest level of recommendation in national treatment guidelines, which requires that at least 80 percent of people taking part in a clinical trial complete it in order for the study to be considered for high-level guideline approval. This helps create an artificial appearance that the newer drug is the better choice, says Callaghan.

But in fact, the trials of other medications for diabetic neuropathy had 70 percent or more completion rates, he says - not an appreciable difference.

And even though older generic drugs without a specific indication for diabetes pain must be prescribed "off label" by doctors, the evidence that they work is powerful - including the evidence from the new meta-analysis by the Mayo-led team.

Callaghan, who sees diabetic neuropathy patients at the U-M Health System, says he prescribes generic drugs, gabapentin or one of the tricyclic antidepressants, routinely as the first option for new pain.

The authors looked at the cost of one month of the typical starting dose for each of these medications. According to, pregabalin is the most expensive at $189.98 per month, followed by duloxetine at $170.99 per month. Although venlafaxine is generic, its cost remains high at $119.98 per month. In contrast, gabapentin comes in at $18.99 per month, amitriptyline at $12.99 per month, and nortriptyline at $19.99 per month. A topical cream of capsaicin, available over the counter without a prescription, costs the least: $13.99 per month.

"The Mayo study supports other systematic reviews on this issue," he says. "We hope that adding in the cost consideration will be useful to neurologists and primary care physicians alike, since we all treat patients with painful diabetic neuropathy."
Callaghan, an assistant professor in the Department of Neurology, is also a member of the U-M Institute for Healthcare Policy and Innovation. Feldman is the Russell DeJong Professor of neurology and director of the A. Alfred Taubman Medical Research Institute.

Reference: Annals of Internal Medicine: Mayo study: doi:10.7326/M14-0511

U-M commentary: doi:10.7326/M14-2157

University of Michigan Health System

Related Diabetes Articles from Brightsurf:

New diabetes medication reduced heart event risk in those with diabetes and kidney disease
Sotagliflozin - a type of medication known as an SGLT2 inhibitor primarily prescribed for Type 2 diabetes - reduces the risk of adverse cardiovascular events for patients with diabetes and kidney disease.

Diabetes drug boosts survival in patients with type 2 diabetes and COVID-19 pneumonia
Sitagliptin, a drug to lower blood sugar in type 2 diabetes, also improves survival in diabetic patients hospitalized with COVID-19, suggests a multicenter observational study in Italy.

Making sense of diabetes
Throughout her 38-year nursing career, Laurel Despins has progressed from a bedside nurse to a clinical nurse specialist and has worked in medical, surgical and cardiac intensive care units.

Helping teens with type 1 diabetes improve diabetes control with MyDiaText
Adolescence is a difficult period of development, made more complex for those with Type 1 diabetes mellitus (T1DM).

Diabetes-in-a-dish model uncovers new insights into the cause of type 2 diabetes
Researchers have developed a novel 'disease-in-a-dish' model to study the basic molecular factors that lead to the development of type 2 diabetes, uncovering the potential existence of major signaling defects both inside and outside of the classical insulin signaling cascade, and providing new perspectives on the mechanisms behind insulin resistance in type 2 diabetes and possibly opportunities for the development of novel therapeutics for the disease.

Tele-diabetes to manage new-onset diabetes during COVID-19 pandemic
Two new case studies highlight the use of tele-diabetes to manage new-onset type 1 diabetes in an adult and an infant during the COVID-19 pandemic.

Genetic profile may predict type 2 diabetes risk among women with gestational diabetes
Women who go on to develop type 2 diabetes after having gestational, or pregnancy-related, diabetes are more likely to have particular genetic profiles, suggests an analysis by researchers at the National Institutes of Health and other institutions.

Maternal gestational diabetes linked to diabetes in children
Children and youth of mothers who had gestational diabetes during pregnancy are at increased risk of diabetes themselves, according to new research published in CMAJ (Canadian Medical Association Journal).

Two diabetes medications don't slow progression of type 2 diabetes in youth
In youth with impaired glucose tolerance or recent-onset type 2 diabetes, neither initial treatment with long-acting insulin followed by the drug metformin, nor metformin alone preserved the body's ability to make insulin, according to results published online June 25 in Diabetes Care.

People with diabetes visit the dentist less frequently despite link between diabetes, oral health
Adults with diabetes are less likely to visit the dentist than people with prediabetes or without diabetes, finds a new study led by researchers at NYU Rory Meyers College of Nursing and East Carolina University's Brody School of Medicine.

Read More: Diabetes News and Diabetes Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to