A number of different treatments for neuropathic pain have been studied, but the literature
is sizable, rapidly evolving, and lacks important information about practical aspects
of patient management. Under the auspices of the International Association for the
Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), a consensus
process was used to develop evidence-based guidelines for the pharmacologic management
of neuropathic pain that take into account clinical efficacy, adverse effects, impact
on health-related quality of life, convenience, and costs. On the basis of randomized
clinical trials, medications recommended as first-line treatments for neuropathic
pain included certain antidepressants (i.e., tricyclic antidepressants and dual reuptake
inhibitors of both serotonin and norepinephrine), calcium channel alpha(2)-delta ligands
(i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol
were recommended as second-line treatments that can be considered for first-line use
in selected clinical circumstances. Other medications that generally would be used
as third-line treatments include certain other antidepressant and antiepileptic medications,
topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists. Two
other national and international associations recently published pharmacologic treatment
guidelines for neuropathic pain, which are summarized and contrasted with the NeuPSIG
recommendations. Recent guidelines for the use of neurostimulation for the treatment
of neuropathic pain also are summarized. For all treatments for neuropathic pain,
long-term studies, head-to-head comparisons, and studies of treatment combinations
are a priority for future research.