Lancet Neurol

Meta-analysis examines safety and efficacy of drugs and neuromodulation for neuropathic pain

June 19, 2025

Study details: This systematic review and meta-analysis by the Neuropathic Pain Special Interest Group (NeuPSIG) included 313 double-blind, randomized, placebo-controlled trials (n=48,789) evaluating pharmacological and non-invasive neuromodulation interventions for neuropathic pain, with a focus on responder rates (≥30% or ≥50% pain reduction) and withdrawals due to adverse events.

Results: Tricyclic antidepressants (TCAs), gabapentinoids (α2δ-ligands), and serotonin-norepinephrine reuptake inhibitors (SNRIs) had the most favorable balance of effectiveness (NNTs between 4.6 and 8.9) and tolerability (NNHs between 13.9 and 26.2), justifying their strong recommendation as first-line treatments. Second-line therapies, such as capsaicin 8% patches, capsaicin cream, and lidocaine 5% plasters, had higher NNTs but were well tolerated. Third-line options—including botulinum toxin A, repetitive transcranial magnetic stimulation (rTMS), and opioids—were weakly recommended due to limited evidence or safety concerns. Overall, treatment benefits were modest, and some interventions had wide confidence intervals or low certainty of evidence.

Clinical impact: The NeuPSIG review updates and refines prior recommendations, emphasizing TCAs, gabapentinoids, and SNRIs as first-line agents, with topical and neuromodulation therapies reserved for refractory cases.

Source:

Soliman N, et al; NeuPSIG Review Update Study Group. (2025, May). Lancet Neurol. Pharmacotherapy and non-invasive neuromodulation for neuropathic pain: a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/40252663/