Which medication is commonly used first for neuropathic pain such as diabetic neuropathy?

• A. Gabapentin
• B. Morphine
• C. Acetaminophen
• D. Ketamine

Answer: (A)

Neuropathic pain from conditions like diabetic neuropathy is best addressed with a medication that specifically targets nerve hyperexcitability. Gabapentin, a gabapentinoid, is commonly used first because it modulates calcium channels in the nervous system, which reduces the release of excitatory neurotransmitters and dampens abnormal nerve firing that drives neuropathic pain. This mechanism provides meaningful relief for many patients with diabetic neuropathy and generally carries a safer profile than opioids, especially for long-term use. Start with a low dose and titrate up to minimize dizziness, sedation, and ataxia, and adjust for kidney function since dosing depends on renal clearance. Ketamine and acetaminophen aren’t first-line for neuropathic pain, with ketamine reserved for refractory cases and acetaminophen more suited to nociceptive pain. Morphine can help some types of pain but is not the preferred first option for neuropathic pain due to limited efficacy and higher risk of dependence and adverse effects.