From the Guidelines
Medications for peripheral neuropathy include gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments, as recommended by the most recent guidelines 1.
Treatment Options
The following medications are considered first-line treatments for neuropathic pain:
- Gabapentinoids, such as gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) and pregabalin (starting at 75mg twice daily, up to 300-600mg daily)
- Serotonin-norepinephrine reuptake inhibitors, such as duloxetine (60-120mg daily)
- Tricyclic antidepressants, such as amitriptyline (10-25mg at bedtime, increasing to 25-150mg if needed)
- Sodium channel blockers, such as lidocaine patches (5%) or capsaicin cream (0.075%) for localized neuropathic pain
Key Considerations
- Treatment should start with low doses and gradually increase to minimize side effects like dizziness, sedation, and dry mouth
- Patients should expect gradual improvement over weeks rather than immediate relief
- Combining medications from different classes may provide better pain control than single agents alone
- Refer to a neurologist or pain specialist when adequate pain management is not achieved within the scope of practice of the treating clinician 1
Evidence-Based Recommendations
The most recent guidelines from the American Diabetes Association recommend the use of gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers as initial pharmacologic treatments for neuropathic pain in diabetes 1. These recommendations are based on the latest evidence and prioritize the management of pain and improvement of quality of life for patients with peripheral neuropathy.
From the FDA Drug Label
The efficacy of the maximum recommended dose of pregabalin for the management of neuropathic pain associated with diabetic peripheral neuropathy was established in three double-blind, placebo-controlled, multicenter studies 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
The medications for peripheral neuropathy are: