Medications for Painful Peripheral Neuropathy

Dr.Saeid Khezer Family physician Kurdistan /

Duhok

2016.11.29

Medications for Painful Peripheral Neuropathy

1. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Medications for Painful Peripheral Neuropathy

2. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Anticonvulsants : May be more effective in sharp lancinating pain

Gabapentin (Neurontin) Adjust for renal dysfunction Start at 100 mg at bedtime to 100 mg orally three time

daily Advance to 300 orally three times daily (maximum 1200

mg three times daily)

Medications for Painful Peripheral Neuropathy

2. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Pregabalin (Lyrica) Very similar to Gabapentin, but no generic yet available and expensive More convenient dosing (twice daily), and no Renal Dosing adjustment

as contrasted with Gabapentin Start at 50 mg orally two to three times daily Titrate to 100 mg orally three times daily or 150 mg twice daily

(maximum 300 mg twice daily) Other agents

Other anticonvulsants (including Carbamazepine, Topiramate) do not have adequate evidence to support use

Medications for Painful Peripheral Neuropathy

3. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Serotonin-Norepinephrine Reuptake Inhibitors

Duloxetine (Cymbalta) Start at 20 mg twice daily Advance to 60 mg daily (or divided 30 mg twice daily)

Venlafaxine (Effexor) Extended release (preferred): Venlafaxine XR 37.5 mg daily

(titrate to 225 mg daily) Regular (generic): Venlafaxine 37.5 mg twice daily (titrate

to 225 mg divided twice daily)

Medications for Painful Peripheral Neuropathy

4. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Topical pain management

TENS Unit Lidocaine 5% patch (Lidoderm) up to 3 patches applied daily

to affected area (applied for no more than 12 hours daily) Capsaicin 0.075% cream applied to affected area twice daily

(start with small amount and slowly increase) Isosorbide Dinitrate spray 30 mg applied to bottom of feet

at bedtime

Medications for Painful Peripheral Neuropathy

5. Tricyclic Antidepressants; May be more effective in burning, steady pain Avoid in the elderly due to strong 

Anticholinergic effects Amitriptyline or Nortriptyline :Started at 10-30

mg at bedtimeIncrease to 50-75 mg (maximum 150 mg) at

bedtime Desipramine : starting at 25 mg at bedtime

Analgesics

NSAIDS are not typically recommended in Diabetes Mellitus Risk of renal, gastrointestinal and cardiovascular risks

Tramadol (Ultram) See Tramadol for precautions (lower efficacy with adverse

effect risk) Opioids (avoid unless no other option available)

Prevention

 Diabetic Foot Care

Optimize Diabetes Mellitus management (Hemoglobin A1C <7-8%)

Optimize Hypertension and Hyperlipidemia Management

References Aring (2005) Am Fam Physician 71:2123-30 [PubMed] Backonja (1998) JAMA 280:1831-36 [PubMed] Kochar (2004) QJM 97:33-8 [PubMed] Lindsay (2010) Am Fam Physician 82(2): 151-8 [PubMed] Lipnick (1996) Am Fam Physician 54(8):2478-84 [PubMed] McQuay (1996) Pain 68:217-27 [PubMed] Simmons (2000) Clinical Diabetes 18:116-7 [PubMed] Sindrup (1990) Pain 42:135-44 [PubMed] Snyder (2016) Am Fam Physician 94(3): 227-34 [PubMed] Veves (2008) Pain Med 9(6): 660-74 [PubMed] Wong (2007) BMJ 335(7610): 87 [PubMed]

Thank you