From the Guidelines
Duloxetine (30-60mg daily) is the most effective antidepressant for treating nerve pain, as supported by the most recent and highest quality study 1.
Introduction to Treatment Options
When considering treatment for nerve pain, it's essential to weigh the benefits and risks of various medications. Antidepressants, particularly tricyclic antidepressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly prescribed for nerve pain management.
Mechanism of Action and Efficacy
These medications work by increasing levels of neurotransmitters (serotonin and norepinephrine) that inhibit pain signals in the spinal cord and brain. Among SNRIs, duloxetine and venlafaxine are frequently prescribed, with duloxetine being the most effective option, as supported by two high-quality studies and five medium-quality studies 1.
Treatment Considerations
Treatment typically requires 2-4 weeks before pain relief begins, and should continue for at least 3-6 months if effective. Common side effects of TCAs include dry mouth, constipation, dizziness, and drowsiness, while SNRIs may cause nausea, headache, and insomnia. These medications should be started at low doses and gradually increased to minimize side effects, and should not be stopped abruptly as withdrawal symptoms may occur.
Key Points to Consider
- Duloxetine (30-60mg daily) is the most effective antidepressant for treating nerve pain 1.
- Venlafaxine (75-225mg daily) is also an effective option, but may have more severe adverse events in older people 1.
- TCAs, such as amitriptyline, nortriptyline, and desipramine, are also effective, but may have more side effects and require careful dosing 1.
- Treatment should be individualized and monitored closely to minimize side effects and maximize efficacy.
From the FDA Drug Label
Diabetic Peripheral Neuropathic Pain: nausea, somnolence, decreased appetite, constipation, hyperhidrosis, and dry mouth Fibromyalgia: nausea, dry mouth, constipation, somnolence, decreased appetite, hyperhidrosis, and agitation. Chronic Pain due to Osteoarthritis: nausea, fatigue, constipation, dry mouth, insomnia, somnolence, and dizziness. Chronic Low Back Pain: nausea, dry mouth, insomnia, somnolence, constipation, dizziness, and fatigue
Duloxetine is used for the treatment of:
- Diabetic Peripheral Neuropathic Pain (DPNP)
- Fibromyalgia (FM)
- Chronic Pain due to Osteoarthritis (OA)
- Chronic Low Back Pain (CLBP) 2
From the Research
Antidepressants for Nerve Pain
- The following antidepressants have been studied for their effectiveness in treating nerve pain:
- Duloxetine: a balanced serotonin and noradrenaline reuptake inhibitor, has been shown to be effective in treating painful diabetic peripheral neuropathy, fibromyalgia, and chronic musculoskeletal pain 3, 4, 5
- Amitriptyline: a tricyclic antidepressant, has been compared to duloxetine and pregabalin in the treatment of diabetic peripheral neuropathic pain, with similar analgesic efficacy 6
- Venlafaxine: a selective serotonin-norepinephrine reuptake inhibitor, is recommended as a primary treatment for neuropathic pain, along with duloxetine and gabapentin 7
Effective Dosages
- Duloxetine: 60 mg daily has been shown to be effective in treating painful diabetic peripheral neuropathy and fibromyalgia, with a risk ratio for ≥ 50% pain reduction at 12 weeks of 1.73 (95% CI 1.44 to 2.08) 3
- Amitriptyline: 75 mg per day, pregabalin: 600 mg per day, and duloxetine: 120 mg per day, were the maximum tolerated doses used in a comparative study of diabetic peripheral neuropathic pain treatment 6
Combination Therapies
- Combination of duloxetine with pregabalin, amitriptyline with pregabalin, and pregabalin with amitriptyline, have been studied for their efficacy in treating diabetic peripheral neuropathic pain, with similar analgesic efficacy and improved pain relief in patients with suboptimal pain control with monotherapy 6