# Painful peripheral neuropathy - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Nervous System Disorders 2025 · Amitriptyline 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683) · Duloxetine Dr. Reddy's 60 mg Gastro-Resistant Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 6966) · Bodman MA, Dreyer MA, Varacallo MA. Diabetic Peripheral Neuropathy. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK442009; PMID: 28723038. · Alzain 75 mg Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 1762) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Nervous System Disorders 2025 - Amitriptyline 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683) - Duloxetine Dr. Reddy's 60 mg Gastro-Resistant Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 6966) - Bodman MA, Dreyer MA, Varacallo MA. Diabetic Peripheral Neuropathy. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK442009; PMID: 28723038. - Alzain 75 mg Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 1762) ## Treatment metadata - Duloxetine — 60 mg — oral.solid - Pregabalin — 75 mg — oral.solid - Amitriptyline — 25 mg — oral.solid ## Complete treatment card ```text PAINFUL PERIPHERAL NEUROPATHY Sources: Egyptian National Drug Formulary - Nervous System Disorders 2025 · Amitriptyline 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683) · Duloxetine Dr. Reddy's 60 mg Gastro-Resistant Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 6966) · Bodman MA, Dreyer MA, Varacallo MA. Diabetic Peripheral Neuropathy. [Updated 2024 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Bookshelf ID: NBK442009; PMID: 28723038. · Alzain 75 mg Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 1762) Review status: REVIEWED against 5 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (10) - Feet that burn, tingle or go numb, and are worse at night [night-time symptoms] - Odd foot sensations that patients describe vaguely, leaving walking and daily tasks difficult - In about 80% the loss follows a stocking-and-glove pattern, which can take years to build up - Autonomic gut effects: belly discomfort, trouble swallowing, nausea, constipation, loose stool, leaking stool [abdominal pain · constipation · difficulty swallowing · nausea] - Autonomic heart effects: low blood pressure, fast or swinging pulse, blackouts [hypotension] - Autonomic bladder effects: weak stream, straining to pass urine, a bladder that never fully empties [poor urinary stream] - Autonomic skin effects: cannot tolerate heat, drenching sweats, sweating while eating [heat intolerance · sweating] - Nerve entrapments and palsies also occur: carpal tunnel, neck or low back root pain, and third, fourth, sixth and seventh cranial nerve involvement - Varying degrees of numbness, tingling, ache, burning, limb weakness, hyperalgesia, allodynia and pain [hyperalgesia · numbness · tingling] - The pain is superficial, deep-seated, or severe and unremitting, and it flares at night SIGNS - what you find (5) - Examine the legs for power, reflexes and sensation, testing light touch with a monofilament, vibration and joint position sense - Dry, cracked skin points to autonomic damage; clawed or hammer toes point to motor damage - Reduced light touch and absent ankle jerks show up early in the course - Loss of protective sensation comes late, sometimes only once an ulcer has already formed - In about half of diabetic cases the neuropathy is asymmetric TESTS (11) - Screen at diagnosis in type 2 diabetes; in type 1 start 5 years after diagnosis, then every year - Small nerve fibres are checked by temperature change or pinprick - Large fibres are checked by vibration: time how long a 128 Hz fork is felt at the big toe joint, normally 18 seconds - The 10 g monofilament gauges ulcer risk, but a patient can still feel it after an ulcer has developed - Needle EMG and nerve conduction studies hurt, cost money, and mostly interrogate the large myelinated fibres - Skin nerve fibre density testing is what assesses the small unmyelinated fibres - Send to neurology for special testing only when features are atypical: fast onset, heavy motor weakness, or sensation abnormal on one side only - EMG and nerve conduction studies are for severe or fast-worsening symptoms, or for motor weakness - Intraepidermal nerve fibre density is the test of choice for small fibre disease; skin biopsy is worth it when no cause is found - Mild symptoms need no bloods; if they persist unexplained, check glucose, HbA1c, blood count, ESR, syphilis serology, serum electrophoresis and vitamins B1, B6 and B12 - Red flag: a neuropathic foot ulcer heals badly and can go on to local then systemic infection, septicaemia and death IF NOT THIS - what else fits (6) - Nerve damage caused by alcohol - Nerve damage from poor nutrition - Nerve damage from kidney failure - Nerve damage from inflamed blood vessels - Vitamin B12 deficiency - Nerve damage from toxic metals Source StatPearls "Diabetic Peripheral Neuropathy" - disease-level clinical article Status traced to the source above 1. DULOXETINE [1st line] Adult 60 mg once daily with or without food; max 120 mg daily in divided doses - long-term Peds Not indicated for neuropathic pain in children Choice Sourced preference. The condition's own article sets out its drug therapy in two tiers: first line, the gabapentinoids - pregabalin, gabapentin - and duloxetine; second line, the serotonin and norepinephrine reuptake inhibitors such as venlafaxine, and the tricyclic antidepressants such as amitriptyline. Duloxetine is named on the first tier and amitriptyline is not. Pregabalin sits on that same first tier as the co-equal alternative; duloxetine is printed because pregabalin carries a dependence and withdrawal warning on its own label and is a controlled drug to dispense. Source Duloxetine Dr. Reddy's 60 mg Gastro-Resistant Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 6966) Why Duloxetine is an SNRI that boosts serotonin and norepinephrine in the descending pain- modulating pathways, offering an alternative mechanism to pregabalin for painful peripheral neuropathy. The condition's cited article puts it on the first line of its drug therapy, alongside the gabapentinoids - pregabalin, gabapentin. Caution Avoid in end-stage renal disease (CrCl < 30 mL/min) or severe hepatic impairment. Monitor blood pressure periodically (risk of dose-dependent hypertension). There is a risk of serotonin syndrome when combined with other serotonergic agents. Egypt DULOPRESSIVE 60 MG 30 CAPS. GLOBAL NAPI P... 174.00 EGP (5.80/unit) DEPRETREVE 60MG 20 CAPS. INTERNATIONAL... 148.00 EGP (7.40/unit) DULOXEPRIN 60 MG 28 CAPS. FUTURE PHARMA... 214.00 EGP (7.64/unit) CYMBATEX 60 MG 30 CAPS. EVA PHARMA 295.50 EGP (9.85/unit) DUCANDES 60 MG 28 CAPSULES MASH PREMIERE... 280.00 EGP (10.00/unit) CYMBALTA 60 MG 28 CAPS. ELI LILLY 544.00 EGP (19.43/unit) DUXNORZET 60 MG 30 DEL. REL. H.G. CAPS. ZETA PHARMA 231.00 EGP WADILOXTIN 60 MG 28 DEL. REL. CAPS. WADI ELNEEL BENTA 280.00 EGP 2. PREGABALIN [1st line] Adult 150 mg per day in two or three divided doses (75 mg twice daily); may increase to 300 mg per day after an interval of 3 to 7 days and, if needed, to a maximum of 600 mg per day after an additional 7 days Peds Safety and efficacy have not been established in children below 12 years or in adolescents 12-17 years of age. Source Alzain 75 mg Capsules, Hard SmPC section 4.2 Posology and method of administration (eMC product 1762) Why Pregabalin binds the alpha-2-delta subunit of voltage-gated calcium channels on nerve terminals, reducing excitatory neurotransmitter release; this condition's cited article names gabapentinoids a first-line agent for painful diabetic peripheral neuropathy. Caution Treatment should be given for the shortest possible duration; agree a plan for stopping before starting, to minimise the risk of dependence, addiction and withdrawal. Dizziness and somnolence are common; caution when driving or operating machinery. Reduce dose in renal impairment based on creatinine clearance. Do not discontinue abruptly; taper over at least 1 week to avoid withdrawal symptoms. There is potential for misuse and dependence. Egypt FORPREGAB 75 MG 30 CAPS. GRAND PHARMA ... 45.00 EGP (1.50/unit) SNAPGAB 75 MG 30 CAPS. MASH PREMIERE... 49.50 EGP (1.65/unit) LYRIBALIN 75MG 10 CAPS. BORG 18.00 EGP (1.80/unit) NEURAGABALIN 75 MG 10 CAPS. DELTA GRAND P... 23.00 EGP (2.30/unit) NERVATYCA 75 MG 20 CAPS. ALFACURE PHAR... 48.75 EGP (2.44/unit) QUEENLEPT 75 MG 30 CAPS. FUTURE PHARMA... 93.00 EGP (3.10/unit) LYRICA 75MG 20 CAPS. PFIZER 232.00 EGP (11.60/unit) PREGABEDIUM 75 MG 20 H.G. CAPS. SABAA > ACTIV... 56.66 EGP LOCIKASWAB 100MG/5ML 20 UNIDOSE ORAL SOLN. UNISWAB > VODACHEM 43.50 EGP -> ? strength differs, ? different route - not oral solid AVEROPREG 100MG/5ML SYRUP 60 ML AVERROES PHAR... 55.50 EGP -> ? strength differs, ? different route - not oral solid 3. AMITRIPTYLINE [2nd line] Adult 10-25 mg at bedtime initially, titrate by 10-25 mg weekly to 50-75 mg nightly (usual maximum 75 mg nightly) - long-term Peds Amitriptyline should not be used in children and adolescents aged less than 18 years, as safety and efficacy have not been established. Source Amitriptyline 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683) Why Second-line agent for painful peripheral neuropathy. The condition's own cited article places the tricyclic antidepressants, amitriptyline among them, on its second line, behind the gabapentinoids and duloxetine. It stays on the card because it is cheap and widely prescribed in Egypt, but it is no longer the printed first choice. Caution Contraindicated in recent myocardial infarction and heart block. Amitriptyline has strong anticholinergic side effects (dry mouth, urinary retention, constipation, blurred vision). Avoid in elderly patients, and in severe cardiovascular disease or arrhythmias. Amitriptyline - StatPearls - NCBI Bookshelf (NBK537225) puts amitriptyline on the American Geriatrics Society's Beers list, to be avoided in the elderly because its anticholinergic effect is so strong. The label puts the usual range at 25-75 mg nightly and says doses above 100 mg should be used with caution. Egypt TRYPTIZOL 25 MG 30 TABS. KAHIRA 33.00 EGP (1.10/unit) GRANITYLLIN 25MG/5ML SYP. 120 ML GRAND PHARMA ... 5.00 EGP -> ? strength differs, ? different route - not oral solid ZINOTRAVAL 25MG/5ML SYP. 120 ML DEBEIKY > PHA... 10.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)