Severe neuropathic pain from a small fibre neuropathy

A 68 year old lady with severe neuropathic pain from a small fibre neuropathy, possibly secondary to diabetes, was seen in the pain clinic.

On examination she had widespread exaggerated pain from pin prick sensation (allodynia) in the lower limbs, especially below the knees, but no pain from light touch (allodynia). However, she did report feeling hypersensitive to both air and touch, and described the pain as like a burning pain with a dead feeling in the middle of the bones. This she described as severe and constant. She had previously taken a number of different medications including anti-inflammatories, opiates and anti-neuropathic medications, but has suffered with adverse effects from these.

At the end of the consultation she was given a long and frank explanation as to the nature of neuropathic pain and discussed the fact that she had a small fibre neuropathy secondary to her diabetes. It was explained that medication was the first line of treatment for any type of neuropathic pain and in view of the previous multiple adverse effects she had had with medication, we decided to start her on a very low dose of Pregabalin 25 mg at night for one week, increasing to Pregabalin 50 mg at night for 2 weeks.

She was reviewed at 3 weeks and I was very pleased to see that the lady had found great improvement with the medication and with minimal adverse effects. Her medication was gently increased by small increments up to 25 mg in the morning and 75 mg at night. This she found to be of great benefit and she reported much less susceptibility to cold, improved sleeping, improvement in lying down, and overall she felt much better in herself. She was also thankfully not suffering with any adverse effects from the medication and this may have been due to starting with very small doses which were increased very slowly.

We decided to carefully increase the Pregabalin by small amounts further to see if we could improve her symptoms with minimal adverse effects. She was very keen to do this and we decided on a plan to increase the dose by 25 mg every 2 weeks. Given the excellent progress she has made so far, I hope this will continue.