What medications are used to treat neuropathic pain?

From the Guidelines

Neuropathic pain can be effectively managed with several medication options, with first-line treatments including anticonvulsants such as pregabalin (starting at 75mg twice daily, increasing to 300-600mg daily) and gabapentin (starting at 300mg daily and gradually increasing to 1800-3600mg daily in divided doses), as well as antidepressants like duloxetine (60-120mg daily) and venlafaxine (150-225mg daily) 1.

Medication Options

• Anticonvulsants:
  • Pregabalin: starting at 75mg twice daily, increasing to 300-600mg daily
  • Gabapentin: starting at 300mg daily and gradually increasing to 1800-3600mg daily in divided doses
• Antidepressants:
  • Duloxetine: 60-120mg daily
  • Venlafaxine: 150-225mg daily

Mechanism of Action

These medications work by modulating pain signals in the nervous system - anticonvulsants reduce neuronal excitability by blocking calcium channels, while antidepressants increase levels of norepinephrine and serotonin to enhance pain inhibitory pathways 1.

Second-Line Options

For more severe or resistant pain, second-line options include tramadol (50-100mg every 4-6 hours) or topical treatments like lidocaine patches (5%) or capsaicin cream (0.075%) 1.

Treatment Approach

Treatment should start with low doses and gradually increase to minimize side effects, which commonly include dizziness, drowsiness, and dry mouth 1.

Monitoring and Follow-Up

It's essential to allow 2-4 weeks for full effect and to try different medications if the first choice is ineffective, as response varies between individuals 1.

From the FDA Drug Label

Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy Management of postherpetic neuralgia Management of neuropathic pain associated with spinal cord injury Management of fibromyalgia

Pregabalin is used to treat neuropathic pain associated with:

• Diabetic peripheral neuropathy
• Postherpetic neuralgia
• Spinal cord injury
• Fibromyalgia 2, 2

From the Research

Medications for Neuropathic Pain

• First-line treatments include:
  • Anticonvulsants such as pregabalin 3, 4, 5 and gabapentin 4, 5
  • Antidepressants like tricyclic antidepressants 4, 6, serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine 4, 5 and venlafaxine 5
  • Topical agents like lidocaine plasters 4 and capsaicin high concentration patches 4, 5
• Second-line treatments include:
  • Tramadol 4, 5
  • Combination therapies 5, 6
  • Psychotherapy as adjuncts 5
  • High-concentration capsaicin patches and botulinum toxin A for focal peripheral neuropathic pain 4, 5
• Third-line options:
  • Strong opioids when no alternative is available 4, 5, 6
  • High-frequency repetitive transcranial magnetic stimulation (rTMS) targeting the motor cortex 5
  • Spinal cord stimulation 5

Treatment Approach

• A 'low and slow' dosing approach is recommended for pregabalin to limit common side effects and optimize tolerability 3
• Patients should be fully engaged and informed about the expected timeline for efficacy and side effects 3
• A multidisciplinary team approach, including cognitive-behavioral and rehabilitative therapies, is essential for the treatment of neuropathic pain 7, 5, 6
• Treatment should be personalized and based on the underlying mechanism(s) of neuropathic pain according to the quality of the patient's symptoms 7, 4, 5