Low doses of amitriptyline, pregabalin, and gabapentin are preferred for management of neuropathic pain in India: is there a need for revisiting dosing recommendations?

Abstract

BackgroundCurrent therapy for the treatment of neuropathic pain is often unsatisfactory. Considerable variation in treatment pattern still exists in spite of availability of sufficient literature from various guidelines. Recent Indian market data suggested that the utilization (sale) of drugs such as amitriptyline, pregabalin, and gabapentin was more for low-dose unit packs than that of the high-dose unit packs, raising the belief that these drugs are prescribed at a lower dose than is actually recommended in the guidelines. To test this hypothesis, a survey was conducted across speciality throughout the country to observe the prescription pattern of these drugs amongst the health care providers in India.MethodsThree hundred fifty survey forms were distributed of which 281 forms were included for analysis.ResultsIt was observed that the commonly used initiation and maintenance dose for amitriptyline, pregabalin, and gabapentin was 5–10 mg/day, 50–75 mg/day, and 100–300 mg/day, respectively. The reason to select the lower dosages was to have a balancing effect to achieve good efficacy with minimum side effects. Care-givers reported no side effects/not many side effects as a reason in 22.2%, 16.88%, and 23.86% patients with amitriptyline, pregabalin, and gabapentin, respectively. Sedation and giddiness were commonly reported with all three drugs.ConclusionsCommonly prescribed drugs for management of neuropathic pain, such as amitriptyline, pregabalin, and gabapentin are preferred at lower doses in Indian clinical settings. Acceptable efficacy and low tolerance to the standard dosage is believed to be the reason behind the prescribed dose.

Dual action of amitriptyline on NMDA receptors: enhancement of Ca-dependent desensitization and trapping channel block

“…Relatively large ATL concentrations (15–60 µM) are required for the NMDAR channel block 5 . However, this somewhat contradicts clinical observations that neuropathic pain relief by ATL treatment can be rapidly achieved with dosages that are lower than those required for treatment of depression 23 .…”

Pregabalin and gabapentin in neuropathic pain management after spinal cord injury: a systematic review and meta-analysis

“…Neuropathic pain is one of the most challenging medical conditions after spinal cord injury (SCI) [1,2], which is associated with anxiety, depression, and sleep disorders [3][4][5]. It interferes with daily activities and normal functioning [6,7], and has a significant negative impact on the patients' quality of life [7][8][9][10][11][12][13][14][15][16].…”

An Evaluation of Efficacy and Safety of Commonly Prescribed Drugs and Effect of These Drugs on Quality of Sleep in Patients Suffering From Zoster‐Associated Pain

“…Doses of amitriptyline (25 mg) and gabapentin (300 mg) used in the current study were less than those recommended in the British National Formulary for treatment of neuropathic pain, that is, amitriptyline 25 to 150 mg in 2 divided doses and gabapentin 1200 to 3600 mg in 3 divided doses . Kamble et al, in a questionnaire‐based survey that included 281 doctors from 31 cities in India to evaluate prescription pattern of first‐line drugs for neuropathic pain, reported that doses of amitriptyline (10‐25 mg) and gabapentin (100‐300 mg) used were low as compared to the recommendation and were found to be effective with minimal side effects. Results of the present study also suggest that amitriptyline and gabapentin can be effective in low doses, that is, 25 mg/day and 300 mg/day, respectively, in patients with zoster‐associated pain.…”