TABLE 2.
Pharmacologic Therapy for Neuropathic Pain
| ORAL | |||
|---|---|---|---|
| Therapy | Route | Starting Doses |
Maintenance Doses |
| First Line | |||
| Tricyclic anti-depressants | oral | 10–25 mg at bedtime | Increase by 10–25 mg increments to 100–150 mg at |
| Gabapentin (Neurontin) | oral | 300 mg tid | Increase by 300–400 mg increments to 2400-in 3–4 doses |
| Tramadol (Ultram) | oral | 50 mg bid or tid | Increase by 50 mg increments to a maximum of 100 |
| Duloxetine (Cymabalta) | oral | 30 mg a day | Increase by 30 – 60 mg increments up to 120 mg a |
| Pregabalin (Lyrica) | oral | 50 mg tid | Increase to 300 mg/day |
| Second Line | |||
| Venlafaxine XR (Effexor) | oral | 37.5–75 mg once a | Increase by 75 mg increments to 150–225 mg a day |
| Valproate | oral | 250 mg bid to tid | Increase by 250 mg increments up to 1500 mg a day |
| Carbamazepine | oral | 200 mg bid | Increase by 200 mg increments to 200–400 mg three a day; follow drug levels on doses greater than 600 |
| Oxcarbazepine (Trileptal) | oral | 150–300 mg bid | Increase by 300 mg increments to 600–1200 mg two |
| Lamotrigine (Lamictal) | oral | 25 mg once a day or bid | Increase by 25 mg increments weekly to 100 |
| Topiramate (Topamax) | oral | 25–50 mg at bedtime | Increase by 50 mg increments weekly to 200 mg bid |
| Third Line | |||
| Bupropion SR (Welbutrin) | oral | 150 mg a day | After one week, increase to 150 mg bid |
| Tiagabine hydrochloride (Gabitril) | oral | 4 mg a day | Increase to 4 – 12 mg bid |
| Keppra (Levetiracetam) | oral | 250 mg at bedtime | Increase by 250–500 mg increments to 1500 mg two |
| Zonisamide (Zonegran) | oral | 100 mg at bedtime | Increase by 100 mg increments to 400–600 mg at bedtime |
| Mexiletine | oral | 200 mg once a day | Increase by 200 mg increments to a maximum of 200 |
| Phenytoin | oral | 200 mg at bedtime | Increase by 100 mg increments to 300–400 2 doses, following drug levels |
| Newer Drugs | |||
| Savella | oral | 12.5 mg at bedtime × 1 d | 12.5 mg bid × 2 d then 25 mg bid × 4 d the stay on 50 mg bid. May increase up to 100 |
| Vimpat | oral | 50 mg PO bid | In 1week, go to 100 mg bid. May increase up to 2 |
| Topical Agents | |||
| OVER THE COUNTER | |||
| Capsaicin .075% | topical | Apply to affected tid to qid | Continue with starting dose |
| Salicylate 10–15% | topical | Apply to affected tid to qid | Continue with starting dose |
| Menthol 16% / Camphor 3% -+ | topical | Apply to affected tid to qid | Continue with starting dose |
| BY PRESCRIPTION | |||
| Lidocaine 2.5% / Prilocaine 2.5% | topical | Apply to affected tid to qid | Continue with starting dose |
| Lidocaine patch 5% | topical | Apply over adjacent intact skin | Increase up to 3 patches worn for 12 of 24 |
| Doxepin 5% (Zolopan) | topical | Apply to affected bid | Continue with starting dose |
| Diclofenac Sodium (Voltaren Gel 1%) | topical | Apply to affected tid to qid | Continue with starting dose |
| BY PRESCRIPTION - ONLY AT COMPOUNDING PHARMACIES | |||
| Ketoprofen 5% / Amitriptyline 2% / Tetracaine 1% | topical* | Apply to affected bid | Increase up to a qid schedule |
| Ketoprofen 10% / Cyclobenzaprine 1% Lidocaine 5% | topical* | Apply to affected bid | Increase up to a qid schedule |
| Ketamine 5% / Amitriptyline 4% Gabapentin 4% | topical* | Apply to affected bid | Increase up to a tid schedule |
| Carbamazepine 5% Lidocaine 5% | topical* | Apply to affected bid | Increase up to a qid schedule |
| Amitriptyline 2% / Lioresal 2% | topical* | Apply to affected tid to qid | Continue with starting dose |
Key:
*
- must be compounded by pharmacy (to locate your local compounding pharmacy, call the International Academy of Compounding Pharmacists, 1-800-927-4227)