Similarly to other systematic reviews conducted in this area, the authors found that anticonvulsants, serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and topical capsaicin 0.075% are better than placebo for short-term pain control. As few head-to-head studies are available, they used a network meta-analysis to indirectly compare drug classes. Although SNRIs were found to be more effective than anticonvulsants and TCAs more effective than topical capsaicin, results of other comparisons among these four drug classes did not differ significantly. This analysis was however limited by the heterogeneity of the individual studies, the high risk of bias in many, and the short-term follow-up.
Given the lack of direct drug-to-drug comparisons, and the fact that current evidence does not suggest that the effectiveness of these agents substantively differs, the authors of an accompanying editorial suggest that cost, comorbidities and potential adverse effects should be important considerations when considering treatment choice.
The NICE clinical guideline on neuropathic pain (CG173; Nov 2013) recommends initial therapy with amitriptyline, duloxetine, gabapentin or pregabalin; switching to one of the remaining drugs is recommended if the initial treatment is not effective or not tolerated. Capsaicin cream is recommended for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.