Regimen for tricylic antidepressants in neuropathic pain

Treatment should be commenced at a low dose:

• with respect to neuropathic pain:
  • offer oral amitriptyline or pregabalin as first-line treatment
  • for amitriptyline
    • start at 10 mg per day, with gradual upward titration to an effective dose or the person's maximum tolerated dose of no higher than 75 mg per day (higher doses could be considered in consultation with a specialist pain service)

Based on both the early and regular clinical reviews:

• if there is satisfactory improvement, continue the treatment; consider gradually reducing the dose over time if improvement is sustained
• if amitriptyline* as first-line treatment results in satisfactory pain reduction but the person cannot tolerate the adverse effects, consider oral imipramine* or nortriptyline* as an alternative
  • * in these recommendations, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication of NICE guidance (March 2010). Informed consent should be obtained and documented

The summary of product characteristics must be consulted before prescribing the drug mentioned.

Reference:

1. BNF 4.7.3
2. NICE (March 2010). Neuropathic pain (adults) - pharmacological management