Several recommendations regarding the pharmacological treatment of neuropathic pain have been published in the literature^1-6. Overall, there are few differences among the recommendations for treating neuropathic pain. In most, tricyclic antidepressants and calcium channel α₂-δ ligands are often regarded as first-line therapy, while selective serotonin noradrenaline reuptake inhibitors and topical lignocaine are considered first- or second-line treatments. Tramadol and opioid analgesics are regarded as second- or third-line treatment. A few guidelines suggested combination therapy when monotherapy is unsatisfactory^5-7.

Despite these guidelines providing evidence-based recommendations for the treatment of neuropathic pain, studies have shown that successful treatments of neuropathic pain at best provide only partial pain relief for about half of those treated ⁸. In part, this outcome is due to limitations in the existing clinical evidence and research in neuropathic pain. Recent recommendations suggest a more rational strategy for the treatment of neuropathic pain, including taking into consideration the diagnosis, symptoms and likely mechanisms, co-morbidities, and establishing a realistic expectation with the patient. When selecting the appropriate treatment, consider the recommended first-, second- and third-line drugs and avoid drugs with significant adverse effects. Functional and health-related quality of life (HRQOL) outcomes should be measured, and reassessment of the patient after a period of trial therapy is important. There is evidence to suggest combination therapy may be effective if monotherapy fails. The patient should be referred to pain medicine specialists if therapy fails and if early multidisciplinary management is necessary. 

References:

1. Dworkin RH, et al. Pain 2007;132: 237-251.
2. Moulin DE, et al. Pain Res Manag 2007;12:13-21.
3. Finnerup NB, et al. Pain 2005;118:289-305.
4. Attal N, et al. Eur J Neurology 2006;13:1153-1169.
5. Attal N, et al. Eur J Neurology 2010;17:1113-e88.
6. Tan T, et al. BMJ 2010;340:c1079.
7. Acevedo JC, et al. J Pain Palliat Care Pharmacother 2009; 23(3):261-81.
8. Dworkin RH, et al. Mayo Clin Proc 2010; 85(3 Suppl):S3-S14.