Combination Neuropathic Pain Therapy — RACP Adult Medicine MCQ

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ModerateEndocrinology & DiabetesCombination Neuropathic Pain TherapyRACP Adult Medicine

A 68-year-old man with type 2 diabetes and painful diabetic neuropathy has failed pregabalin and duloxetine individually. Both were at maximum tolerated doses. What combination approach should be considered?

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Correct answer: E — Pregabalin + duloxetine combination

When monotherapy with first-line agents (pregabalin, duloxetine, or amitriptyline) fails individually, combining agents from different classes may provide additive benefit. The OPTION-DM trial showed that combination therapy (pregabalin + amitriptyline or duloxetine + pregabalin) was more effective than switching between monotherapies. Topical capsaicin 8% patch can be added as an adjunct for localised neuropathic pain. Opioids are NOT recommended as first- or second-line due to dependence, tolerance, and limited long-term efficacy in neuropathic pain.

Reference: eTG – 2025 – Neurology; OPTION-DM Trial – 2022