Table 2B. Medications Not Approved for DPNP by FDA1 Drug
Dosage Form Recommended Dosage
Second Tier Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Venlafaxine Effexor XR®
37.5, 75, 150 mg tablets
37.5 mg initially once daily with food; titrate in increments based on effectiveness/tolerability to max 225 mg daily (lower dosage if hepatic or renal impairment)
■ Use if nonresponsive to or intolerant of first-tier agents
■ Contraindicated if concomitant MAOIs, uncontrolled narrow- angle glaucoma
■ Avoid other SNRIs, TCAs, tramadol
Tricyclic antidepressants (TCAs)2
Amitriptyline Elavil®
generics ,
10, 25, 50, 75, 100, 150 mg tablets
10-25 mg initially at bedtime; titrate in increments of 10-25 mg based on effectiveness/tolerability to 100-150 mg/d
Desipramine Norpramin® Pertofrane®
generics , ,
10, 25, 50, 75, 100, 150 mg tablets
10 mg/d initially at
■ Oldest, best known, commonly used as gold standard of TCAs
■ Contraindicated if age > 60 yr, concomitant use of MAOIs, any cardiovascular disease (prolongs QT intervals) ■ Avoid SNRIs, tramadol
bedtime; titrate in increments of 10-25 mg based on effectiveness/tolerability to 50-100 mg/d
Nortriptyline Aventyl® Pamelor®
, generics ,
10, 25, 50, 75 mg capsules
10 mg/d initially at
bedtime; titrate in increments of 10-25 mg based on effectiveness/tolerability to 50-100 mg/d
■ Active metabolite of imipramine
■ Contraindicated if concomitant use of MAOIs, any cardiovascular disease (prolongs QT intervals) ■ Avoid SNRIs, tramadol
■ Active metabolite of amitriptyline
■ Avoid SNRIs, tramadol
■ If discontinuing therapy, taper off gradually
Comments
1 If treatment plan includes these agents, obtain written patient consent. 2
Patients with depressive symptoms should be adequately screened for risk of bipolar disorder before initiating treatment with TCAs. Analgesic effect of TCAs is independent of their antidepressant effect and must be weighed against adverse events associated with these agents, making them less well tolerated than SNRIs or SSRIs.
