American Board of Internal Medicine (ABIM) Certification Practice Exam

Which class of medications is first-line for treating severe neuropathic pain in diabetes mellitus?

1. Antidepressants

2. Opioids

3. Anticonvulsants

4. Sodium channel blockers

The correct answer is: Antidepressants

The first-line class of medications for treating severe neuropathic pain in diabetes mellitus is antidepressants, particularly the tricyclic antidepressants such as amitriptyline and nortriptyline. These medications are effective in managing neuropathic pain due to their ability to alter pain perception through various mechanisms, including the modulation of neurotransmitters involved in pain regulation. Antidepressants work by increasing the availability of serotonin and norepinephrine in the synaptic cleft, which plays a crucial role in pain modulation. Their effectiveness is not limited to patients who are clinically depressed; they can provide beneficial effects in the context of pain management even in the absence of mood disorders. In patients with diabetes mellitus, neuropathic pain can be a significant complication that adversely affects quality of life. Therefore, the ability of antidepressants to alleviate such pain makes them a suitable first-line option. While other classes of medications, such as anticonvulsants and sodium channel blockers, also have roles in managing neuropathic pain, the evidence supports antidepressants as the preferred initial treatment in this scenario.