What are the treatment options for neuropathic pain?

From the Guidelines

Neuropathic pain treatment should prioritize gabapentinoids, such as pregabalin, and serotonin-norepinephrine reuptake inhibitors, like duloxetine, as first-line medications due to their efficacy and relatively safer profile compared to opioids. These medications have been shown to be effective in reducing neuropathic pain and improving quality of life, with studies such as 1 supporting their use.

First-Line Treatment Options

• Gabapentinoids: Pregabalin (starting at 75mg twice daily, increasing to 300-600mg daily) is a recommended option, with eight high-quality studies supporting its role in treating pain in diabetic neuropathy 1.
• Serotonin-norepinephrine reuptake inhibitors: Duloxetine (60-120mg daily) is another effective option, with two high-quality studies and five medium-quality studies supporting its use in treating pain in diabetic neuropathy 1.

Second-Line Treatment Options

• Tricyclic antidepressants: Amitriptyline (10-25mg at bedtime, increasing to 25-150mg) can be considered, although its use may be limited by anticholinergic side effects, particularly in older individuals 1.
• Topical treatments: Capsaicin patches (8%, applied by healthcare professionals every 3 months) can be used in patients with contraindications to oral pharmacotherapy or who prefer topical treatments 1.

Opioid Use

Opioids, such as tapentadol, should be avoided as first- or second-line therapy due to their high risk of addiction and relatively modest pain reduction. This is supported by studies such as 1, which found the evidence for tapentadol's effectiveness in reducing neuropathic pain to be inconclusive.

Non-Pharmacological Approaches

Non-pharmacological approaches, including physical therapy, cognitive behavioral therapy, and transcutaneous electrical nerve stimulation (TENS), should be incorporated alongside medications to improve functional outcomes and quality of life. Treatment success should be measured not just by pain reduction but also by functional improvement and quality of life, with regular reassessment every 4-6 weeks during dose titration.

From the FDA Drug Label

The efficacy of pregabalin for the management of neuropathic pain associated with spinal cord injury was established in two double-blind, placebo-controlled, multicenter studies Treatment with pregabalin 150–600 mg/day statistically significantly improved the endpoint weekly mean pain score, and increased the proportion of patients with at least a 30% and 50% reduction in pain score from baseline The recommended dose range of pregabalin for the treatment of neuropathic pain associated with spinal cord injury is 150 to 600 mg/day

Treatment of Neuropathic Pain: Pregabalin is indicated for the management of neuropathic pain associated with spinal cord injury. The recommended dose range is 150 to 600 mg/day, with a starting dose of 75 mg two times a day (150 mg/day). The dose may be increased to 150 mg two times a day (300 mg/day) within 1 week based on efficacy and tolerability. Patients who do not experience sufficient pain relief after 2 to 3 weeks of treatment with 150 mg two times a day and who tolerate pregabalin may be treated with up to 300 mg two times a day 2.

From the Research

Treatment Options for Neuropathic Pain

• Neuropathic pain can be treated with various medications, including gabapentin, pregabalin, and duloxetine 3, 4, 5, 6, 7
• Gabapentin is effective in treating painful diabetic neuropathy, postherpetic neuralgia, and other neuropathic pain syndromes, with doses ranging from 900 mg/d to 3600 mg/d 3, 4
• Pregabalin has shown superior results compared to gabapentin in alleviating neuropathic pain, with improved patient-reported outcomes and lower opioid consumption 7
• Combination therapy, such as morphine + pregabalin or morphine + duloxetine, can produce a synergistic effect on mechanical allodynia, but not on neuroma pain 6

Efficacy and Safety of Gabapentin and Pregabalin

• Gabapentin is effective in relieving symptoms of allodynia, burning pain, shooting pain, and hyperesthesia, with adverse effects typically mild to moderate 3
• Pregabalin has demonstrated superior efficacy and safety compared to gabapentin, with significant improvements in quality of life and fewer adverse events 7
• Gabapentin has a higher incidence of nausea and vomiting compared to pregabalin 7

Recommendations for Treatment

• Selective serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine, gabapentin, and tricyclic antidepressants are primary treatments for neuropathic pain 5
• Pregabalin is a first-line treatment according to international guidelines, but second-line in French guidelines due to lower efficacy and misuse risk 5
• Topical lidocaine and transcutaneous electrical nerve stimulation are specifically suggested for focal peripheral neuropathic pain 5