This site is intended for health professionals only

NICE advises amitriptyline first-line for neuropathic pain

By Lilian Anekwe

NICE has published its first-ever guidance recommending which drugs GPs should prescribe adults with neuropathic pain, and in what order.

Neuropathic pain affects an estimate 1 in every 50 adults in the UK, including those suffering from such as diabetes, HIV, cancer, shingles, multiple sclerosis, stroke or who have had limb amputations and other surgical procedures, and around 95% of patients are prescribed drugs to manage the pain.

GPs should prescribe amitriptyline or pregabalin as a first line treatment, or oral duloxetine patients who have painful diabetic neuropathy.

Patients who continue to suffer from neuropathic pain at the maximum tolerated dose of a first-line drug should be prescribed a drug from another therapeutic class – for example, amitriptyline if they have already been prescribed pregabalin, either in combination with the original drug.

Patients who do not respond to first and/or second-line drugs should be referred to a specialist for further treatment.

While patients are waiting to be seen in secondary care GPs can prescribe oral tramadol alongside the ongoing second-line treatment, or topical lidocaine if they have localised pain and are unable to take medication orally.

GPs should only prescribe opioids if they have been initiated by a secondary care specialist.

Professor Blair Smith, a GP in Peterhead, Aberdeenshire and a member of the NICE guideline development group said: ‘Although neuropathic pain is seen by many GPs, treating it effectively can very much be a trial and error process.

‘Treating neuropathic pain in its own right, rather than as a symptom of multiple other diagnoses, will give GPs a straightforward approach to managing this complex condition.'

The guidance is available on the NICE website.


Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.