Figure 11. Algorithm for the Management of Symptomatic Diabetic Neuropathy. Non-pharmacological, topical, or physical therapies can be useful at any time (capsaicin, acupuncture, etc.). The only drugs approved in the US for the treatment of painful diabetic neuropathy are pregabalin, duloxetine, and tapentadol ER. However, based on the NNT (number needed to treat), tricyclic antidepressants are the most cost-effective ones. SNRIs: serotonin and norepinephrine reuptake inhibitors. Modified from Vinik et al.Vinik (278) 2010