What are the treatment options for peripheral neuropathy pain?

From the Guidelines

Duloxetine is the recommended first-line treatment for peripheral neuropathy pain, with a dose of 30 mg/day for 1 week, then 60 mg/day, as it has shown a moderate clinical benefit in patients with painful chemotherapy-induced peripheral neuropathy 1. The treatment of peripheral neuropathy pain typically involves a multi-faceted approach combining medications, lifestyle modifications, and sometimes procedures.

• First-line medications include anticonvulsants such as gabapentin or pregabalin, but the evidence for their use in peripheral neuropathy is not as strong as for duloxetine 1.
• Antidepressants, particularly duloxetine, are effective in treating peripheral neuropathy pain, with duloxetine being the only studied drug in a large randomized trial showing a moderate clinical benefit in patients with painful chemotherapy-induced peripheral neuropathy 1.
• Topical treatments like lidocaine patches or capsaicin cream can provide localized relief with fewer systemic side effects, but their effectiveness in peripheral neuropathy is not well established 1.
• For severe cases, tramadol or other opioids may be considered short-term, but their long-term use carries significant risks, and there is limited evidence to support their use in peripheral neuropathy 1. The medications work by modulating pain signals in the nervous system, with anticonvulsants reducing neuronal excitability, antidepressants enhancing inhibitory pain pathways, and topicals blocking local pain signals. Non-pharmacological approaches, including physical therapy, exercise, proper nutrition, and stress management, are important complementary strategies, but there is limited evidence to support their effectiveness in peripheral neuropathy. Patients should monitor for side effects like dizziness, drowsiness, and weight gain, and regular follow-up with healthcare providers is essential to assess treatment effectiveness, with the goal of improving quality of life and reducing morbidity and mortality. The most recent and highest quality study, published in 2020, supports the use of duloxetine as the first-line treatment for peripheral neuropathy pain, and this recommendation is based on the strongest available evidence 1.

From the FDA Drug Label

Pregabalin is indicated for: Management of neuropathic pain associated with diabetic peripheral neuropathy The efficacy of duloxetine delayed-release capsules for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults was established in 2 randomized, 12-week, double-blind, placebo-controlled, fixed-dose trials in adult patients having diabetic peripheral neuropathic pain (DPNP) for at least 6 months

The treatment options for peripheral neuropathy pain are:

• Pregabalin: indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy 2
• Duloxetine: efficacy established for the management of neuropathic pain associated with diabetic peripheral neuropathy in adults 3

From the Research

Treatment Options for Peripheral Neuropathy Pain

The treatment options for peripheral neuropathy pain include:

• Drug therapy, with the most frequently suggested drugs being amitriptyline, duloxetine, gabapentin, and pregabalin 4
• Gabapentin as a first-line drug for the treatment of neuropathic pain in spinal cord injury 5
• Combination therapy, such as amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin 6
• Amitriptyline, pregabalin, and duloxetine for the treatment of painful diabetic peripheral neuropathy, with amitriptyline showing more favorable findings with tolerable side effects 7
• Gabapentin alone or combined with vitamin B complex for the treatment of diabetic neuropathic pain, with preliminary results showing significant reduction in pain and improvement in quality of life 8

Commonly Used Medications

Some of the commonly used medications for peripheral neuropathy pain include:

• Amitriptyline
• Duloxetine
• Gabapentin
• Pregabalin
• Opioids (although they are often recommended as second or third line treatment) 4

Combination Therapy

Combination therapy may be effective in improving pain relief in patients with suboptimal pain control with monotherapy, with studies showing that combination treatment was well tolerated and led to improved pain relief 6

• Amitriptyline supplemented with pregabalin
• Pregabalin supplemented with amitriptyline
• Duloxetine supplemented with pregabalin

Side Effects

Common side effects of these medications include:

• Drowsiness
• Dizziness
• Dry mouth
• Nausea 6, 7, 8