Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology

Figures & data

Table 1 Treatment options for postherpetic neuralgia

Therapy	Dosage	Most common adverse reactions in clinical trials
First line
Calcium channel α2-δ ligands
Gabapentin	Starting dose 100–300 mg at bedtime or 100–300 mg three times daily. Increase dose by 100–300 mg three times every 1–7 days as tolerated up to a maximum of 3,600 mg/day.a,b,^Citation29	Dizziness, somnolence, peripheral edema, diarrhea, asthenia, infection, dry mouth, constipation, nausea, vomiting, accidental injury, ataxia, abnormal thinking, blurred vision.c,^Citation33
Gastroretentive gabapentin	Starting dose 300 mg/day. Increase dose by 300 mg/day on days 2, 3, 7, 11, and 15 up to a maximum dose of 1,800 mg/day.b,^Citation35	Dizziness, somnolence, headache, peripheral edema, diarrhea.c,^Citation35
Gabapentin enacarbil	Starting dose 600 mg in the morning. Increase dose to 600 mg twice daily on day 4.b,^Citation37	Dizziness, somnolence, headache, nausea, fatigue/asthenia, peripheral edema, insomnia, weight gain.c,^Citation37
Pregabalin	Starting dose 50 mg three times daily or 75 mg twice daily as tolerated. Increase dose to 300 mg/day after 3–7 days, and then by 150 mg/day every 3–7 days as tolerated up to a maximum of 600 mg/day.a,b,^Citation29	Dizziness, somnolence, peripheral edema, ataxia, blurry vision, abnormal gait, headache, weight gain, confusion, edema, abnormal thinking, abnormal vision, pain, accidental injury, constipation, diplopia, amnesia, infection, flatulence, vomiting, incoordination, speech disorder, bronchitis.c,^Citation41
Tricyclic antidepressants
Nortriptyline   Desipramine	Starting dose 25 mg at bedtime. Increase dose by 25 mg/day every 3–7 days as tolerated up to a maximum of 150 mg/day; if blood concentration of active medication and its metabolite are <100 ng/mL, continue titration with caution.a,b,^Citation29	Dry mouth, weight gain, drowsiness.^Citation52
Topical agents
Lidocaine 5% patch	Apply every 4–12 hours; up to three patches per day.^Citation29	Application-site reactions (blisters, bruising, burning sensation, depigmentation, dermatitis, discoloration, edema, erythema, exfoliation, irritation, papules, petechiae, pruritus, vesicles), asthenia, confusion, disorientation, dizziness, headache, hyperesthesia, hypoesthesia, lightheadedness, metallic taste, nausea, nervousness, pain exacerbated, paresthesia, somnolence, taste alteration, vomiting, visual disturbances such as blurred vision, flushing, tinnitus, and tremor.^Citation53
Second or third line
Opioid analgesics
Oxycodone	Titration: morphine oral equianalgesic dosages of 10–15 mg every 4 hours; after 1–2 weeks, convert total daily dosage to long-acting opioid analgesic and continue short-acting agent as needed; no maximum dosage, but consider evaluation by a pain specialist at doses ≥120 mg daily or equianalgesic dosage.^Citation29	Constipation, nausea, somnolence, dizziness, pruritus, vomiting, headache, dry mouth, asthenia, sweating, insomnia, asthenia.^Citation54,Citation55
Morphine		Constipation, dizziness, sedation, nausea, vomiting, sweating, dysphoria, euphoric mood, somnolence.^Citation56,Citation57
Methadone		Lightheadedness, dizziness, sedation, nausea, vomiting, and sweating.^Citation58
Tramadola,d	Starting dose at 50 mg one to two times per day; titrated in 50–100 mg increments in divided doses every 3–7 days; maximum dosage 400 mg/day (100 mg four times per day); maximum dosage for the elderly 300 mg/day.^Citation29	Dizziness, nausea, constipation, headache, somnolence, flushing, pruritus, vomiting, insomnia, dry mouth, diarrhea, asthenia, postural hypotension, sweating, anorexia.^Citation58
Topical agents and creams
Capsaicin 8% patch	Up to four patches for 1 hour every 3 months or longer; needs to be administered by a physician or trained personnel; a topical anesthetic is applied to the affected area before capsaicin patch.^Citation59	Application-site reactions (pain, burning, erythema, pruritus, papules, edema), nausea, vomiting.^Citation59
Capsaicin 0.075% cream	Apply three to five times per day.

Notes:

a Consider lower starting dosages and slower titration in geriatric patients.

b Reduce dosage if impaired renal function.

c Adverse effects occurring in three or more patients treated at the maximum recommended dose.

d Dosages given for the short-acting formulation.

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Neurontin® (gabapentin) [package insert]New York, NYParke-Davis Division of Pfizer, Inc2015

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Gralise® (gabapentin) [package insert]Newark, CADepomed, Inc2012

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Horizant® (gabapentin enacarbil) [package insert]Santa Clara, CAXenoPort, Inc2013

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Lyrica® (pregabalin) [package insert]New York, NYParke-Davis Division of Pfizer Inc2013

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DerrySWiffenPJAldingtonDMooreRANortriptyline for neuropathic pain in adults [review]Cochrane Database Syst Rev20151CD01120925569864

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Lidoderm® (lidocaine patch 5%) [package insert]Malvern, PAEndo Pharmaceuticals, Inc2015

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Oxycontin® (oxycodone HCl) [package insert]Stamford, CTPurdue Pharma L.P2015

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Roxicodone® (oxycodone hydrochloride tablets USP) [package insert]Hazelwood, MOMallinckrodt, Inc2014

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Morphine Oral Solution (morphine sulfate) [package insert]Hazelwoood, MOMallinckrodt, Inc2014

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MS CONTIN® (morphine sulfate extended-release tablets) [package insert]Hazelwood, MOMallinckrodt, Inc2014

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ULTRAM® ER (tramadol) [package insert]Titusville, NJJanssen Pharmaceuticals, Inc2014

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Qutenza® (capsaicin) 8% patch [package insert]Ardsley, NYAcorda Therapeutics, Inc2013

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