Adjuvant analgesics: gabapentinoids, antidepressants, ketamine and lidocaine
Mechanisms of neuropathic pain and the drugs that target them, gabapentinoid kinetics and renal dosing, antidepressant analgesia, sodium channel blockers, ketamine and lidocaine, with NeuPSIG NNTs and the harms that matter.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Neuropathic pain comes from ectopic firing in damaged nerves (sodium channel upregulation) and central sensitisation (NMDA receptor activation, loss of inhibitory interneurons, reduced descending inhibition).
- Adjuvants target these: alpha-2-delta ligands reduce transmitter release, TCAs and SNRIs strengthen descending noradrenergic inhibition, sodium channel blockers quieten ectopic discharge, ketamine blocks NMDA.
- First line (NeuPSIG 2015 and TG): TCAs, SNRIs, pregabalin, gabapentin. Second line: lidocaine 5% plaster, capsaicin 8% patch, tramadol. Third line: strong opioids, botulinum toxin A.
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Sources
- Therapeutic Guidelines: Pain and AnalgesiaAU/NZTherapeutic Guidelines Limited, 2024
- Therapeutic Guidelines: Palliative CareAU/NZTherapeutic Guidelines Limited, 2024
- Australian Medicines HandbookAU/NZAustralian Medicines Handbook Pty Ltd, 2026
- Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis (NeuPSIG)Lancet Neurol (Finnerup et al., 2015;14:162-73), 2015
- Trial of pregabalin for acute and chronic sciatica (PRECISE)N Engl J Med (Mathieson et al., 2017;376:1111-20), 2017
- Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case-control studyPLoS Med (Gomes et al., 2017;14:e1002396), 2017
- Last updated
- 14 November 2026
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