What is the treatment for neuropathic pain?

From the Guidelines

Neuropathic pain treatment should start with gabapentinoids, serotonin-norepinephrine reuptake inhibitors (SNRIs), or topical capsaicin.

Treatment Options

• Gabapentinoids: include pregabalin and gabapentin, which have been shown to be effective in treating neuropathic pain in diabetic peripheral neuropathy (DPN) 1.
• SNRIs: such as duloxetine and venlafaxine, have also been found to be effective in treating neuropathic pain in DPN 1.
• Topical capsaicin: can be considered for patients with contraindications to oral pharmacotherapy or who prefer topical treatments 1.

Key Considerations

• Dose titration: is crucial when initiating treatment with gabapentinoids or SNRIs to minimize adverse effects 1.
• Adverse effects: such as dizziness, sedation, and nausea, can be dose-dependent and may require careful monitoring and adjustment of medication 1.
• Opioid use: should be avoided due to the high risk of addiction and safety concerns 1.

Treatment Approach

• Stepwise approach: start with a single medication and reassess pain and health-related quality of life frequently, adding or switching medications as needed 1.
• Individualized treatment: consider each patient's presentation, comorbidities, and preferences when selecting a treatment option 1.
• Multidisciplinary care: may be necessary for patients with complex or refractory neuropathic pain 1.

From the Research

Treatment Options for Neuropathic Pain

The treatment of neuropathic pain is challenging due to its heterogeneous etiologies and lack of objective diagnostic tools. Several studies have investigated the treatment options for neuropathic pain, including:

• Pharmacological treatments, such as:
  • Gabapentinoids, tricyclic antidepressants (TCAs), and selective serotonin noradrenaline reuptake inhibitors (SNRIs) as first-line treatments 2, 3
  • Anticonvulsants, such as pregabalin and gabapentin, as first-line treatments 3
  • Topical lidocaine and opioids as second- and third-line treatments 3
  • Antidepressants, antiepileptics, topical anesthetics, and opioids as mainstay treatments 4
• Non-pharmacological treatments, such as:
  • Psychological approaches, physical therapy, interventional therapy, spinal cord stimulation, and surgical procedures 4
  • Acupuncture, massage therapy, and reflexology, although the current evidence supporting their use is not strong 5
• Combination therapies, which are generally employed for the management of neuropathic pain 5, 6

First-Line Treatments

First-line treatments for neuropathic pain include:

• Anticonvulsants, such as gabapentin and pregabalin 2, 3
• Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors 2, 3, 6 These treatments have been shown to be effective in reducing neuropathic pain, although they may have modest efficacy or dose-limiting side effects 2.

Emerging Therapies

There is emerging evidence for the use of cannabinoids in the treatment of neuropathic pain, although conclusive studies are not available 5. Additionally, botulinum toxin A has been investigated as a potential treatment for certain neuropathic pain syndromes, such as trigeminal neuralgia pain 6.