Selecting a Treatment Regimen
Drug* (Brand)
Table 3. Pain Medications Not FDA-Approved for PHN Adverse Effects
Amitriptyline, imipramine, nortriptyline, desipramine
SNRIs** ***
Desvenlafaxine ER Pristiq®
Duloxetine Cymbalta®
Venlafaxine Effexor®
Anticonvulsants
Carbamazepine (CBZ) Tegretol® Tegretol®
-XR
Lamotrigine Lamictal®
Sedation, ataxia, rash, diplopia, hyponatremia, agranulocytosis, nausea, diarrhea, hepatotoxicity, aplastic anemia, Stevens–Johnson syndrome
Headache, dizziness, ataxia, rhinitis, rash, diplopia, blurred vision Warning: Serious skin rashes, hypersensitivity, acute multiorgan failure, blood dyscrasias, suicidality, withdrawal seizures
Phenytoin Dilantin®
Topiramate Topamax®
Valproic Acid Depakane® Stavzor® Depakote ER®
Opioids
Tramadol*** Ultram®
Tapentadol NucyntaTM
Morphine, codeine, fentanyl, hydromorphone, oxycodone, oxymorphone (with appropriate dose conversion)
Respiratory depression, ataxia, sedation, constipation, seizures, nausea, orthostatic hypotension
Nausea, dizziness, vomiting, sleepiness, headaches and serotonin syndrome
Respiratory depression, sedation, nausea, constipation, cognitive dysfunction
25 mg qAM; increase by 25-50 mg q3d
50-100 mg q4-6h 5-15 mg (short-acting)
q4h as needed; aſter 1-2 wk convert to long-acting preparation and continue dose titration as needed
*See PI for details. **Black Box Warning: suicidality. ***Risk of serotonin syndrome. Suicide risk increases in addiction-prone patients, as well as those taking antidepressants or tranquilizers.
Nystagmus, ataxia, dizziness, insomnia, dyskinesias, nausea, vomiting, blood dyscrasias, hypersensitivity
Fatigue, somnolence, weight loss, purpura, fatigue, injury
Somnolence, asthenia, dyspepsia, nausea, vomiting, diarrhea, dizziness Warning: Hepatotoxic, teratogenic, pancreatitis
100-200 mg/d, in divided doses bid; increase dose weekly by 100-200 mg/d
25 mg/d
Hypertension, ataxia, sedation, insomnia, nausea, hyperhidrosis, dry mouth, constipation, anxiety, anorexia
Sedation, ataxia, nausea, dry mouth, constipation, hyperhidrosis, anorexia
Hypertension, ataxia, sedation, insomnia, nausea, hyperhidrosis, dry mouth, constipation, anxiety, anorexia
50 mg daily
60 mg once daily; 60 mg q12h also safe and effective
37.5 mg daily; increase dose weekly by 37.5 mg/d
Cardiac conduction block, orthostatic hypotension, sedation, confusion, urinary retention, dry mouth, constipation, weight gain
Dose
Tricyclic antidepressants** *** (not recommended for older people, "banned" on the Beers' list, and not to be taken with other serotonin enhancing meds)
10-25 mg/d, at bedtime or in divided doses q12h; increase dose weekly by 10-25 mg/d
100 mg tid
Init: 25 mg bid Increase weekly by 50 mg/d
10-15 mg/kg/d increase by 5-10 mg/kg/wk
