Recommended drug classes for treatment of neuropathic or nociplastic pain

Drug	Effective dose	Comments
First-line therapies^*
Antiseizure medications		Can cause dizziness and sedation; minimize with slow titration Use lower doses for older patients Avoid concomitant use with opioids; can cause respiratory depression
Gabapentin	IR: 300 to 1200 mg orally three times daily ER: 600 to 1800 mg orally twice daily	Initiate treatment at a low dose (typically 300 mg orally at night), increasing gradually until pain relief or limiting side effects occur
Pregabalin	150 to 300 mg orally twice daily	Initiate treatment at low dose (typically 150 mg orally at night)
Antidepressants
Serotonin-noradrenaline reuptake inhibitors
Duloxetine	IR: 60 to 120 mg orally once daily
Venlafaxine	ER:75 to 225 mg orally once daily
Tricyclic antidepressants (TCAs)		Initiate treatment at low dose, increase slowly at weekly intervals May take 6 to 8 weeks, including 2 weeks at highest tolerated dose, for adequate trial
Nortriptyline	25 to 75 mg orally once daily	Preferred among TCAs due to less sedation and fewer anticholinergic effects
Amitriptyline	25 to 125 mg orally once daily	Most sedating TCA
Second-line therapies
Capsaicin 8% patch	1 to 4 patches to painful area for 30 to 60 minutes every three months	For peripheral pain Long term safety not established
Lidocaine patch	1 to 3 patches to painful area for ≤12 hours in a 24 hour period, patch-free period of ≥12 hours	For peripheral pain
Tramadol	IR: 100 to 200 mg orally three times daily ER: 100 to 200 mg orally twice daily
Refractory pain
Botulinum toxin A	50 to 200 units subcutaneously to painful area every 3 months	Specialist use, for peripheral pain
Strong opioids	Individual titration	Not routinely used for chronic pain Use only at lowest effective dose, after risk assessment, and with ongoing assessment of risks and benefits Use in combination with nonpharmacologic and nonopioid pharmacologic therapy

For further information refer to UpToDate content on the pharmacologic management of chronic pain and the management of specific neuropathic pain conditions.

ER: extended release; IR: immediate release.

* Initial therapy for neuropathic pain should be based on the pain condition (if known), patient comorbid conditions, concurrent medications, medication side effect profile, cost, and patient preference regarding dosing frequency.

Graphic 127937 Version 5.0

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Recommended drug classes for treatment of neuropathic or nociplastic pain