Why is amitriptyline not considered first line therapy for neuropathic pain?

Amitriptyline is not considered first-line therapy for neuropathic pain primarily due to its significant anticholinergic effects. These effects can lead to various undesirable side effects, particularly in elderly patients or those with other underlying conditions. Anticholinergic effects may include dry mouth, constipation, blurred vision, urinary retention, and confusion, all of which can impact a patient's quality of life and adherence to treatment.

While other factors such as efficacy, cost, and sedation may play a role in selecting treatments for neuropathic pain, the prominent anticholinergic burden associated with amitriptyline makes it less favorable when trying to minimize side effects in patients, especially in populations that may be more sensitive to these effects. This characteristic positions it behind newer medications that might offer similar or improved efficacy with fewer side effects, contributing to the evolving landscape of neuropathic pain management.