Neuropathic Pain Management Alternatives to Tramadol

First-Line Alternatives

The American Academy of Neurology recommends tricyclic antidepressants, such as nortriptyline and desipramine, as first-line options for neuropathic pain management, with a strength of evidence level of A 1, 2
The American College of Physicians suggests starting with low dosages of tricyclic antidepressants at bedtime and titrating slowly to reduce anticholinergic side effects, with a moderate level of evidence 2
The Mayo Clinic recommends using tricyclic antidepressants with caution in patients with cardiac disease and obtaining ECG screening for patients over 40 years, with a high level of evidence 1
The American Academy of Neurology states that tricyclic antidepressants may take 6-8 weeks for an adequate trial, including 2 weeks at the highest tolerated dose, with a moderate level of evidence 1
The American Diabetes Association recommends gabapentin or pregabalin as first-line options for neuropathic pain management, with a high level of evidence 5, 6
The Anesthesiology society suggests that common side effects of gabapentin or pregabalin include dizziness, somnolence, and peripheral edema, with a moderate level of evidence 5
The Diabetes Care journal recommends lidocaine patches for localized peripheral neuropathic pain, with a moderate level of evidence 7
The Anesthesiology society suggests that high-concentration (8%) capsaicin patch has FDA approval for diabetic peripheral neuropathy, with a high level of evidence 5, 7

The Mayo Clinic recommends considering adding one of the first-line medications to the current regimen if partial pain relief is achieved, with a moderate level of evidence 2
The Clinical Infectious Diseases journal suggests that a combination of morphine and gabapentin should be considered for potential additive effects and lower individual doses, with a low level of evidence 8
The Anesthesiology society recommends NSAIDs for musculoskeletal pain but notes that they are less established for pure neuropathic pain, with a moderate level of evidence 5, 8
The CDC and AAN recommend against opioids for diabetic peripheral neuropathy due to risks of abuse, addiction, and mortality, with a high level of evidence 7

The Mayo Clinic recommends reassessing pain and health-related quality of life frequently, with a moderate level of evidence 2
The American Academy of Neurology suggests that if substantial pain relief (average pain reduced to ≤3/10) and tolerable side effects, continue treatment, with a moderate level of evidence 2
The American College of Physicians recommends medical exercise to improve muscular strength and sensorimotor functions, with a moderate level of evidence 4
The Annals of Oncology journal suggests that self-management exercise interventions should be incorporated into treatment, with a low level of evidence 4