From the Guidelines
For neuropathic pain, duloxetine is the medication with the least sedating effects, typically starting at 30mg daily and gradually increasing to 60mg daily as tolerated, due to its minimal sedation and the added benefit of treating depression if present, as supported by the most recent and highest quality study 1.
Medication Options
- Anticonvulsants like gabapentin (starting at 300mg daily, gradually increasing to 300-600mg three times daily as tolerated) and pregabalin (starting at 75mg twice daily, increasing to 150-300mg twice daily as needed) are also good options, but may cause more sedation than duloxetine, as noted in 1 and 1.
- Topical treatments like lidocaine patches (5%) or capsaicin cream (0.025-0.075%) applied to painful areas can provide localized relief without systemic sedation, as suggested in 1.
Mechanism of Action
- These medications work by modulating pain signals through different mechanisms - anticonvulsants reduce neuronal excitability, SNRIs enhance pain inhibitory pathways, and topicals block local pain signals.
Treatment Approach
- It's essential to start at low doses and gradually increase to minimize side effects, as recommended in 1 and 1.
- Morning dosing of potentially sedating medications can also help reduce daytime drowsiness.
- If one medication is ineffective or causes unacceptable side effects, trying another class is recommended before moving to more sedating options like tricyclic antidepressants or opioids, as suggested in 1 and 1.
From the Research
Least Sedation Med for Neuropathy
The following medications are considered to have a lower sedation profile for the treatment of neuropathy:
- Duloxetine, which is a selective serotonin-norepinephrine reuptake inhibitor (SNRI) 2, 3, 4, 5, 6
- Gabapentin, an anticonvulsant medication 2, 3, 4, 6
- Pregabalin, also an anticonvulsant medication, although it may have a higher sedation profile compared to duloxetine and gabapentin 2, 3, 4, 5, 6
Comparison of Medications
Studies have compared the efficacy and safety of these medications:
- A randomized controlled trial found that pregabalin and duloxetine were effective in managing taxane-induced sensory neuropathy, but pregabalin was more effective in decreasing neuropathic pain severity 5
- A cost-effectiveness analysis found that duloxetine was the most cost-effective option for painful diabetic neuropathy, followed by desipramine and gabapentin 6
Treatment Options
Other treatment options for neuropathy include: