From the Guidelines
Medications for neuropathic pain typically include anticonvulsants, antidepressants, and topical agents as first-line treatments, with gabapentin and pregabalin being effective anticonvulsants, and duloxetine and amitriptyline being effective antidepressants. The most recent and highest quality study, 1, recommends the use of gabapentinoids, serotonin-norepinephrine reuptake inhibitors (SNRIs), sodium channel blockers, tricyclic antidepressants (TCAs), and SNRI/opioid dual-mechanism agents for the treatment of neuropathic pain.
Some key points to consider when treating neuropathic pain include:
- Starting with low doses and titrating up to effective doses, such as gabapentin starting at 300mg daily and titrating up to 1800-3600mg daily in divided doses, and pregabalin starting at 75mg twice daily, up to 300-600mg daily
- Using antidepressants such as duloxetine (60-120mg daily) and amitriptyline (10-25mg at bedtime, increasing to 25-150mg if needed) to increase serotonin and norepinephrine levels and inhibit pain pathways
- Considering topical options such as lidocaine 5% patches applied to painful areas for 12 hours daily and capsaicin 8% patches applied by healthcare providers
- Monitoring patients regularly for efficacy and adverse effects, with medication trials lasting 4-8 weeks to properly assess response
- Combining medications from different classes may provide better relief than monotherapy for difficult cases, as suggested by 1
It's also important to note that treatment should be individualized based on pain severity, comorbidities, and potential side effects, and that patients with inadequate response may require consideration of second- or third-line treatments, such as opioids, although these carry risks of dependence, as mentioned in 1.
From the FDA Drug Label
What is pregabalin Pregabalin is a prescription medicine used in adults, 18 years of age and older to treat:
- pain from damaged nerves (neuropathic pain) that happens with diabetes
- pain from damaged nerves (neuropathic pain) that follows healing of shingles
- fibromyalgia (pain all over your body)
- pain from damaged nerves (neuropathic pain) that follows spinal cord injury
The medication for neuropathic (nerve) pain is pregabalin. It is used to treat various types of neuropathic pain, including:
- Diabetic neuropathy
- Postherpetic neuralgia (pain after shingles)
- Fibromyalgia
- Neuropathic pain after spinal cord injury 2
From the Research
Medications for Neuropathic Pain
The following medications are used to treat neuropathic pain:
- Gabapentin: effective in reducing pain, improving sleep, mood, and quality of life 3, 4, 5, 6, 7
- Tricyclic antidepressants (TCAs): first medication to prove effective for neuropathic pain in placebo-controlled trials, but may produce intolerable side effects 3, 4, 5, 6, 7
- 5% lidocaine patch: recommended as a first-line treatment for neuropathic pain 3, 4, 6
- Opioid analgesics: effective, but not considered a first choice due to adverse drug reactions and concerns about abuse, diversion, and addiction 3, 4, 5, 6, 7
- Tramadol hydrochloride: recommended as a first-line treatment for neuropathic pain 3, 6
- Pregabalin: recommended as a first-line treatment for neuropathic pain, particularly for painful diabetic peripheral neuropathy and postherpetic neuralgia 4, 6, 7
- Duloxetine: recommended as a first-line treatment for neuropathic pain 6, 7
- Carbamazepine: approved by the US Food and Drug Administration (FDA) for the treatment of neuropathic pain 6
- Venlafaxine: recommended as a first-line treatment for neuropathic pain 6
Combination Therapy
Combination therapy may be necessary to optimize analgesia and minimize side effects 5
- Gabapentin combined with morphine achieved better analgesia at lower doses of each drug than each drug alone, with only mild adverse effects 3
Treatment Guidelines
Current guidelines recommend the following medications as first-line treatments for neuropathic pain: