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Pharmacologic (Drug) Options

 

You should consult your local pain clinic for advice specific to  your case.  The following drugs have been found to be useful by some people.  Some have found greater relief than others, and some have not found any of them to be particularly helpful.  There is nothing that I have found that has eliminated the pain, but some have decreased it somewhat.

The literature suggests that current therapies can result in a 30 to 50% reduction in pain.  This is helpful, but not total elimination of pain that all of us would like to achieve.

I am not a strong advocate of taking medications, and I like to be drug free.   Others do not mind taking drugs.  My advice would be to follow your physicians advice, but to let him/her know your personal biases so that the therapy can be appropriate for both your condition and your preferences.

Currently I know of no guidelines available from professional organizations for the treatment of painful neuropathy.

I have included a small amount of information on each drug that has been mentioned to me as possibly useful.  You may find more information on each drug by searching the internet using the names provided.  Again, your particular therapy should be directed by your physician.

Antidepressant Drugs

Tricyclic Antidepressants

These drugs have been well studied.    They are reported to reduce pain by 50% in about a third of patients.  The side effects can be a problem for some people.

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Amitriptyline (Elavil) - Member of the tricyclic antidepressant family

This is a commonly used first line drug for chronic pain, including nerve pain.  It may be the best drug available for chronic nerve pain, however it also has significant side effects.  These include drowsiness, constipation among others.  Typically the dose used for nerve pain is less than that for treatment of depression.  I found it made me too tired, even after being on it for a while.  It did dull the pain somewhat, but it took weeks to work.  Many have reported excellent results with this medication.  It may take weeks before the total effect is known.

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Nortryptiline (Pamelor) - Also a member of the tricyclic antidepressant family

Some have found this choice to have less side effects than taking amitriptyline.

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Desipramine - Also a member of the tricyclic antidepressant family

 

Selective Serotonin-Reuptake Inhibitors

Marginal benefit, usually not as good as the tricyclics

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Paroxetine

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Citralopram

Other Antidepressants

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Venlafaxine (Effexor)

Another anti-depressant medication that has been used for chronic pain, with some success.  I have not tried it, and do not know much else about it. 

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Bupropion SR

This is a non-tricyclic antidepressant, which has recently been reported to be effective in treating neuropathic pain.  The reference listed found that most patients reported a decrease in pain when on this medication.  The most common side effects were dry mouth, insomnia and headache.  The long term effectiveness was not studied, as the results were based on a 6 week trial.   REFERENCE

 

ANTICONVULSANT DRUGS

 

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Carbamazepine - Thought to be effective for trigeminal neuralgia, but limited success for other painful sensory neuropathies.  Oxcarbazipine is an analog that is better tolerated in some patients.

 

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Phenytoin - Similar activity to Carbemazepine.  Not used very often as a first line drug for painful neuropathy.

 

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Gabapentin (Neurontin)

Neurontin is one of the newer anti-seizure medications that has been used with some success in treating chronic nerve pain.  It is a very popular drug right now, although it's mechanism of action is unknown, as far as I know.  It does provide some relief, and I have not had too many side effects.   Optimal dosage is still being determined.  My personal experience is that ramping the dosage up slowly was better than trying to ramp it up quickly.  It does have to be taken multiple times a day, because it does not last long (short half-life). 

 

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Lamotrigine (Lamictal)

Another anti-seizure medication that has been used with some success with chronic neuropathic pain.  The mechanism of action is unknown.  

  

ANTIARRHYTMIC DRUGS

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Mexiletine - oral analogue of lidocaine (local anesthetic).  Data is mixed as to whether it is at all helpful.

 

N-Methyl-D-Aspartate Glutamate Antagonists

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Dextromethorphan - Beneficial in some, but causes significant sedation.

 

Narcotic and Nonnarcotic Analgesics

Side effects and concern about addiction remain problems for the narcotics and treatment of chronic pain.

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Oxycodone - Some data indicates it is somewhat effective, but with side effects.

 

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Tramadol - May be as effective with less side effects. 

 

LEVODOPA

Single study indicates some efficacy, not much data at this point.

 

TOPICAL AGENTS

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Capsaicin - effective for some, see other page regarding this.  Cream available for treatment of skin, and some candies available for intra-oral treatment.. 

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Lidocaine - effective for short periods of time, skin and oral formulations available.  See Lidocaine page

OTHERS

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Lioresal (Baclofen)

Usually used for muscle relaxation/spasticity, but has been used by some for chronic nerve pain.  Mechanism of action is unknown as far as I know.

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Tramadol (Ultram)

A pain reliever for moderate to severe pain.  The mechanism, as far as I know, is unknown.  I have tried this once, with limited success.  It has a significant list of contraindications, including some of the other medications on this list.

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Clonazepam  (Klonopin)

Clonazepam is a benzodiazepine, and is commonly used for seizures.  It is used for chronic pain, but is generally not considered a first line drug at this point.  I have found it useful at night, so that I can sleep with the pain.  I have not used this drug during the daytime.  

 

 

References:

N Engl J Med 2003;  348:1243-55

 

 

 

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03/30/03