Which pharmacologic classes are typically used to treat neuropathic pain?

• A. NSAIDs and acetaminophen
• B. Gabapentinoids (gabapentin, pregabalin), SNRIs, TCAs, and topical agents
• C. High-dose opioids as first-line
• D. Beta blockers

Answer: (B)

Treating neuropathic pain relies on medications that reduce nerve excitability or enhance central pain inhibition. Gabapentinoids bind to the alpha-2-delta subunit of voltage-gated calcium channels in overactive nerves, lowering the release of excitatory neurotransmitters and dampening ectopic firing. SNRIs and TCAs increase serotonin and norepinephrine in the spinal cord, strengthening descending inhibitory pathways that suppress pain transmission. Topical agents like lidocaine provide local sodium-channel blockade to reduce spontaneous nerve activity in affected areas, and capsaicin can desensitize nociceptors with repeated use. NSAIDs and acetaminophen target inflammatory nociception and are not specifically effective for neuropathic pain. Opioids are not preferred as first-line for neuropathic pain due to limited efficacy and safety concerns, and beta blockers have no meaningful role here.