Pharmacological treatment of neuropathic pain in older persons

Figures & data

Table 1 Commonly used agents in neuropathic pain: choice of treatment as recommended by three task forces

Drug	Dworkin et al 2003	Attal et al 2006	Moulin et al 2007	Comment
TCA	1	1	1
Gabapentin	1	1	1
Pregabalin	1	1	1
Tramadol	1	2	3
Duloxetine	NR	2	2
Venlafaxine	2	2	2
Lamotrigine	2	2	4
Opioids	1	2	31	1Except methadone
Lidocaine 5% plaster	1	22	2	2First-line in focal neuropathy with allodynia
Topical capsaicin	3	23	3	3PHN only
Valproate	NR	2	4
Topiramate	NR	NE	4
Bupropion	2	NR	NR
Paroxetine	2	NR4	NR	4+ve RCT acknowledged
Citalopram	2	NE	4
Mexiletine	3	NE	4
Clonidine	3	NE	4
NMDA antagonists	3	NE	NR
Methadone	as other opioids	As other opioids	4
Specific indications
Carbamazepine for TGN	1	1	1	No guideline recommends for other NPs
Oxcarbazepine for TGN	NR	1	NR
Cannabinoids for central pain in MS	NR	3	4

1 Note: first-line treatment,

2 second-line treatment,

3 third-line treatment,

4 fourth-line treatment. Note that only Moulin et al (2007) use the category of “fourth-line”.

NR, no recommendation or no discussion; NE, considered not effective.

Table 2 Drug treatment of older persons with neuropathic pain

First line treatment

Tricyclic antidepressants (amitriptyline, nortriptyline)1

Gabapentinoids (gabapentin, pregabalin)

Lidocaine plaster 5%

Carbamazepine and oxcarbazepine in TN2

Second line treatment

Tramadol

Lamotrigine

SNRIs (venlafaxine, duloxetine)

Third line treatment

Opioids (morphine, oxycodone, methadone)3

Cannabinoids in MS4

Citalopram and paroxetine5

Capsaicin

1 Note: In patients with no or stable cardiac conditions only

2 Trigeminal neuralgia

3 Despite efficacy, concerns regarding tolerability make these drugs third line only

4 Data on elderly patients extremely limited

5 In peripheral neuropathies only

DworkinRHCorbinAEYoungJPPregabalin for the treatment of postherpetic neuralgia. A randomized, placebo-controlled trialNeurology20036012748312707429

 PubMed Web of Science ®Google Scholar

AttalNCruccuGHaanpaaMEFNS guidelines on pharmacological treatment of neuropathic painEuropean Journal of Neurology20061311536917038030

 PubMed Web of Science ®Google Scholar

MoulinDEClarkAJGilronIPharmacological management of chronic neuropathic pain – consensus statement and guidelines from the Canadian Pain SocietyPain Res Manage2007121321

 PubMed Web of Science ®Google Scholar