. 2020 Jan 20;6(3):157–167. doi: 10.1159/000504299

Table 3.

Comparison of drug therapy for national and international neuropathic pain guidelines [65, 66, 67, 68]

Guidelines:	CPS [65] updated as of November 2014	NeuPSIG/IASP [66] updated as of January 2015	NICE [67] updated as of February 2017	EFNS [68] updated as of April 2010
Trigeminal neuralgia	First-line: carbamazepine		First-line: carbamazepine Second-line: seek specialist	First-line: carbamazepine, oxcarbazepine Second-line: surgery

Type of neuropathic pain	All neuropathic pain	All neuropathic pain	All neuropathic pain	Central neuropathic pain	Diabetic neuropathy	Post-herpetic neuralgia

First-line	Gabapentin Pregabalin Duloxetine Venlafaxine TCAs	Gabapentin^A Pregabalin Duloxetine Venlafaxine TCAs	Gabapentin Pregabalin Duloxetine Amitriptyline	Gabapentin Pregabalin Amitriptyline TCAs	Gabapentin Pregabalin Duloxetine Venlafaxine ER TCAs	Gabapentin Pregabalin TCAs Lidocaine plasters^B

Second-line	Tramadol CR opioids: Morphine Oxycodone Fentanyl Hydromorphone	Tramadol Capsaicin 8% patches^* Lidocaine patches^*	If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs above ↑, and consider switching again if the second and third drugs tried are also not effective or not tolerated	Tramadol Opioids	Tramadol^C	Opioids: Oxycodone Morphine Methadone Topical capsaicin

Third-line	Cannabinoids	Strong opioids: Oxycodone Morphine Botulinum toxin A^*	Tramadol: acute only Topical capsaicin^*	Opioids	Opioids: Oxycodone

Fourth-line/last-line	Methadone Tapentadol Lamotrigine Topiramate Valproic acid Citalopram Escitalopram Paroxetine Lacosamide Topical capsaicin Topical lidocaine^D Botulinum toxin		Specialist setting: Cannabis sativa extract Lacosamide Lamotrigine Levetiracetam Morphine Oxcarbazepine Topiramate Tramadol: long term Venlafaxine	Lamotrigine^E Cannabinoids^F

For peripheral neuropathy; A, gabapentin immediate release, extended release, and enacarbil; B, topical lidocaine with its excellent tolerability may be considered first line in the elderly, especially if there are 4concerns regarding the CNS side effects of oral medications; C, tramadol may be considered first line in patients with acute exacerbations of pain especially for the tramadol/acetaminophen combination or in patients with predominant coexisting non-neuropathic pain; D, topical lidocaine may be second-line for postherpetic neuralgia; E, lamotrigine may be considered in CPSP or SCI pain with incomplete cord lesion and brush-induced allodynia; F, for multiple sclerosis. We acknowledge the contribution of Caroline Breen and Kangni Wang in compiling this table in collaboration with authors ELW and JF.

Caroline Breen, 2018 PharmD Candidate; Western New England University College of Pharmacy; Springfield, MA, USA

Kangni Wang, 2018 PharmD Candidate; Albany College of Pharmacy and Health Sciences; Albany, NY, USA

Tramadol for as needed use is often difficult to tolerate due to serotonin activity. Tapentadol was approved in Europe in 2011³, EFNS guidelines were last updated in April 2010.

Trigeminal Neuralgia: The reason that we separated out TM is because the EFNS guidelines divides up neuropathy by central neuropathic pain, diabetic neuropathy, post herpetic neuralgia and trigeminal neuralgia. All other guidelines list “all neuropathic pain” indication.

CPSP, central post-stroke pain; CR, controlled release; ER, extended release; SCI, spinal cord injury; TCAs, tricyclic antidepressants; CPS, Canadian Pain Society; NICE, National Institute for Health and Care Excellence; EFNS, European Federation of Neurological Societies; IASP, International Association for the Study of Pain; NeuPSIG, Neuropathic Pain Special Interest Group; CNS, central nervous system.