Specialist GP Resource
Neuropathic Pain Prescribing Guide
Evidence-based medication titration and dosing parameters for Gabapentinoids, Tricyclic Antidepressants, and SNRIs in managing mechanical and radicular neuropathic pain.
Medication Titration Matrix
| Class / Drug | Starting Dose | Titration Pacing | Maintenance Target | Max Limit | Clinical Precautions |
|---|---|---|---|---|---|
| Gabapentinoids Pregabalin (Lyrica) | 25 mg - 75 mg nocte | Increase by 25-75mg every 3-7 days based on tolerance. | 150 mg - 300 mg / day (in 2 divided doses) | 600 mg / day | Renal adjustment required (CrCl < 60ml/min). Drowsiness, peripheral oedema, weight gain. |
| Gabapentinoids Gabapentin (Neurontin) | 100 mg - 300 mg nocte | Increase by 100-300mg every 3-7 days. | 900 mg - 1,800 mg / day (in 3 divided doses) | 3,600 mg / day | Renal adjustment required. Dose-limiting somnolence, dizziness, ataxia. |
| Tricyclic Antidepressants Amitriptyline (Endep) | 5 mg - 10 mg nocte | Increase by 5-10mg every 7 days. | 10 mg - 50 mg nocte | 75 mg nocte | Anticholinergic side effects (dry mouth, urinary retention). Avoid in elderly patients, cardiac conduction delays. |
| SNRIs Duloxetine (Cymbalta) | 30 mg daily | Increase to 60mg daily after 7-14 days. | 60 mg daily | 120 mg / day | Nausea, dry mouth, somnolence, sweating. Monitor blood pressure; avoid in severe renal/hepatic impairment. |
Renal Dosing Adjustments for Gabapentinoids
Both Pregabalin and Gabapentin are exclusively renally cleared and require strict dose adjustments based on estimated Glomerular Filtration Rate (eGFR):
- CrCl 30 - 60 mL/min: Limit Pregabalin to maximum 150 mg / day (in 2 divided doses); Gabapentin to maximum 600 mg / day.
- CrCl 15 - 30 mL/min: Limit Pregabalin to maximum 75 mg / day (single or 2 divided doses); Gabapentin to maximum 300 mg / day.
- CrCl < 15 mL/min: Limit Pregabalin to maximum 25-50 mg / day; Gabapentin to maximum 300 mg every second day.
Discuss Complex Referrals
For patients suffering from severe, drug-resistant radicular neuropathic pain, arrange an urgent referral pathway with Dr Aliashkevich's rooms.