A patient with chronic neuropathic pain from diabetic peripheral neuropathy is being initiated on pharmacotherapy. Which drug class is recommended as FIRST-LINE by EFNS/NeuPSIG guidelines?
- A Tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine, pregabalin/gabapentin) ✓
- B Strong opioids (morphine sustained-release)
- C Topical NSAIDs as monotherapy
- D Benzodiazepines for pain-related anxiety
Explanation
Current NeuPSIG and EFNS guidelines for neuropathic pain recommend as first-line agents: (1) calcium channel alpha-2-delta ligands — pregabalin or gabapentin; (2) serotonin-norepinephrine reuptake inhibitors — duloxetine or venlafaxine; (3) tricyclic antidepressants — amitriptyline or nortriptyline. These agents modulate central sensitisation and descending inhibitory pathways. Strong opioids are second or third-line due to addiction potential, tolerance, and adverse effects. Benzodiazepines have no evidence for neuropathic pain analgesia. Topical lidocaine or capsaicin 8% patches are alternatives for localised neuropathic pain.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
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