Pharmacotherapy for neuropathic pain: Relevant comorbidities for drug selection

Drug class	Comorbidities favoring use	Comorbidities favoring avoidance
Serotonin-norepinephrine reuptake inhibitors (SNRIs): Duloxetine* Venlafaxine	Depression Anxiety	Restless legs syndrome Sexual dysfunction (for venlafaxine) Angle-closure glaucoma Severe hepatic or renal disease
Tricyclic antidepressants (TCAs):^¶ Nortriptyline Desipramine Amitriptyline	Depression Anxiety Insomnia (particularly for amitriptyline)	Cardiac disease Prolonged QTc Orthostatic hypotension Sexual dysfunction Urinary retention Angle-closure glaucoma
Gabapentinoid anticonvulsant medications: Pregabalin^Δ Gabapentin^◊	Restless legs syndrome Essential tremor Insomnia	Substance abuse Peripheral edema Severe renal disease

This table shows some of the comorbidities that may be considered when selecting drugs for the treatment of neuropathic pain. In addition to comorbidities, the choice among treatments should be individualized based on the pain etiology (if known), the patient's age, concurrent medications, medication side effect profile, cost, and patient preference regarding dosing frequency. For further information, refer to UpToDate content on pharmacologic management of chronic pain and content on specific pain conditions.

* Approved by the US Food and Drug Administration (FDA) for diabetic neuropathy, fibromyalgia, chronic low back pain, and osteoarthritis.
¶ None of the TCAs carry an FDA indication for pain management.
Δ FDA approved for painful diabetic neuropathy, postherpetic neuralgia, and neuropathic pain associated with spinal cord injury.
◊ FDA approved for treatment of postherpetic neuralgia.

Graphic 127939 Version 2.0

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Pharmacotherapy for neuropathic pain: Relevant comorbidities for drug selection