Neurology Pharmacotherapy for Neuropathic Pain PDF

Neurology Table 11. Pharmacotherapy for Neuropathic Pain Therapy Route Starting Dose Maintenance Dose PO 10–25 mg at bedtime Increase by 10- to 25-mg increments to 150 mg at bedtime PO 600 mg three times daily Increase by 300- to 400-mg increments to 3600 mg/day in three or four doses PO...

Neurology Table 11. Pharmacotherapy for Neuropathic Pain Therapy Route Starting Dose Maintenance Dose PO 10–25 mg at bedtime Increase by 10- to 25-mg increments to 150 mg at bedtime PO 600 mg three times daily Increase by 300- to 400-mg increments to 3600 mg/day in three or four doses PO 25 mg daily or 50–150 mg/ Increase by 25–150 mg/day at weekly intervals day in two or three divided depending on response. Usual dose: 300–600 mg/day in doses two or three divided doses Serotonin-norepinephrine reuptake inhibitors (SNRIs) • Duloxetine PO 30 mg daily Increase by 30- to 60-mg increments up to 60 mg daily • Venlafaxine Lidocaine 5% PO Topical Increase by 75-mg increments to 225 mg/day Increase up to 3 patches worn for up to 12 hr daily Capsaicin 8% Topical 37.5 mg daily Apply patch or cream over the site of pain 12 hr on, 12 hr off Apply to affected region for 60 min Second Line Tramadol PO 50 mg two or four times daily Increase by 50-mg increments to a maximum of 100 mg four times daily Combination therapy • Gabapentinoid + TCA PO Only use if single agents provided inadequate relief and no adverse effects • Gabapentinoid + SNRI Third Line Carbamazepine PO Titrate as indicated for single agent. Aim for lower doses of both agents PO 200 mg twice daily Lamotrigine PO 25 mg once daily Topiramate PO 25–50 mg at bedtime Valproate PO 250 mg two or three times daily PO • S  hould not be considered until exhausting all pharmacotherapy options above and neurostimulation therapy • Lack of long-term efficacy data and significant adverse effects limit their usefulness • 1 0–15 mg of morphine every 4 hr or PRN (equianalgesic dosages should be used for other opioid dosing) Newer Drugs Milnacipran PO 12.5 mg at bedtime for 1 day Lacosamide PO 50 mg twice daily ORAL AGENTS First Line Tricyclic antidepressants (TCAs) • Nortriptyline • Amitriptyline Gabapentinoids • Gabapentin • Pregabalin Fourth Line Low-dose opioids • Oxycodone • Morphine • Methadone • Levorphanol Continue starting dose Increase by 200-mg increments to 200–400 mg three or four times daily; follow serum concentrations on doses greater than 600 mg/day Increase by 25-mg increments weekly to 100–200 mg twice daily Increase by 50-mg increments weekly to 200 mg twice daily Increase by 250-mg increments up to 1500 mg/day 12.5 mg twice daily for 2 days; then 25 mg twice daily for 4 days; then 50 mg twice daily. May increase up to 100 mg twice daily Increase to 100 mg twice daily after 1 wk. May increase up to 200 mg twice daily ACCP Updates in Therapeutics® 2023: The Pharmacotherapy Preparatory Review and Recertification Course 1-531 Neurology Table 11. Pharmacotherapy for Neuropathic Pain (Cont’d) Therapy Route Starting Dose Maintenance Dose TOPICAL AGENTS OTC Capsaicin 0.075% Topical Continue starting dose Diclofenac sodium gel 1% Topical Salicylate 10%–25% Topical Menthol 16%/ camphor 3% Prescription Lidocaine 2.5%/ prilocaine 2.5% Doxepin 5% Topical Apply to affected region three or four times daily Apply to affected region three or four times daily Apply to affected region three or four times daily Apply to affected region three or four times daily Continue with starting dose Diclofenac sodium gel 1% Topical Apply to affected region three or four times daily Apply to affected region twice daily Apply to affected region three or four times daily Apply to affected area twice daily Increase up to four times daily Apply to affected region twice daily Increase up to four times daily Apply to affected region twice daily Increase up to thrice daily Apply to affected region twice daily Apply to affected region three or four times daily Increase up to four times daily Topical Topical Compounded Prescription Products Topical Ketoprofen 5%/ amitriptyline 2%/ tetracaine 1% Topical Ketoprofen 10%/ cyclobenzaprine 1%/ lidocaine 5% Topical Ketamine 5%/ amitriptyline 4%/ gabapentin 4% Carbamazepine 5%/ Topical lidocaine 5% Amitriptyline 2%/ Topical baclofen 2% Continue with starting dose Continue starting dose Continue with starting dose Continue with starting dose Continue with starting dose Continue with starting dose PO = oral(ly); PRN = as needed. ACCP Updates in Therapeutics® 2023: The Pharmacotherapy Preparatory Review and Recertification Course 1-532