First line drugs used for treating neuropathic pain are following except
Ans. d (Opioids) (Ref Harrison- 17th/ p. 86; 2654; Table 379-6)TREATMENT OF NEUROPATHIC PAIN# General principles:- the first is to move quickly to provide relief;- a second is to minimize drug side effects.# For example, in patients with postherpeutic neuralgia and significant cutaneous hypersensitivity, topical lidocaine (Lidoderm patches) can provide immediate relief without side effects.# First-line drugs: for patients with neuropathic pain.- Anticonvulsants (gabapentin or pregabalin)- Antidepressants (especially serotonin/norepinephrine reuptake inhibitors-SNRIs, e.g., venlafaxine and duloxetine)- Antiarrhythmic drugs (lidocaine and mexiletene).# Second- or third-line drug class:- Opioid medications.# There is no consensus on which class of drug should be used as a first-line treatment for any chronically painful condition. However, because high doses of anticonvulsants are required for pain relief, sedation is very common.# Sedation is also a problem with the tricyclic antidepressants but is much less of a problem with serotonin/norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine and duloxetine).# Thus, in elderly or in those whose daily activities need high-level mental activity, these drugs should be the first line.# In contrast, opioid medications should be used as a second- or third-line drug class. While highly effective for many painful conditions, opioids are sedating, and their effect tends to lessen over time, leading to dose escalation and, occasionally, a worsening of pain due to physical dependence.Treatment of Painful NeuropathyFirst-Line TherapySecond-Line TherapyAntidepressantsOpioidsTricyclicOxycodone 40-160 mg qdAmitriptyline, nortriptyline, imipramine,Morphine 90-360 mg qd POdesimipramine, doxepin (10-150 mg qd)Tramadol 50-400 mg qdSerotonin-noradrenaline reuptake inhibitors (SNRI)Fentanyl patch 25-75 g/h q 3 daysDuloxetine (60-120 mg qd)AntiarrhythmicsVenlafaxine (150-225 mg qd)Mexilitine 600-1200 mg qdAntiepilepticsTopicalCarbamazepine 100-800 mg qdCapsaicin 0.075% topical tid or qidOxcarabazepine 1200-2400 mg qdLidocaine 5% patch bidLamotrigine 200-400 mg qdIsosorbide dinitrate spray 30 mg qhsTopiramate 300-400 mg qdOthersGabapentin 900-3600 mg qdClonidine 0.1-2.4 mg qdPregabalin 150-600 mg qdMemantine 55 mg qdValproic acid 1000-1200 mg qdDextromethorphan 400 mg Levodopa 100 mg tid Alpha-lipoic acid (thioctic acid) 600 mg Spinal cord stimulator Transcutaneous electrical nerve stimulation (TENS)Gabapentin, an anticonvulsant initially studied in the setting of herpetic neuralgia, is now the first-line treatment for neuropathic pain from a variety of causes. It is begun at 100-300 mg bid or tid, with 50-100% dose increments every 3 days. Usually 900-3600 mg/d in two or three doses is effective. One potential side effect to be aware of is confusion and drowsiness, especially in the elderly. Other effective adjuvant medications include pregabalin, which has the same mechanism of action as gabapentin but is more efficiently absorbed from the GI tract. Pregabalin, another newer anticonvulsant is also effective for a broad range of neuropathic pains.Educational TablePainful Conditions that Respond to Tricyclic Antidepressants# Postherpetic neuralgia# Diabetic neuropathy# Tension headache# Migraine headache# Rheumatoid arthritis# Chronic low back pain# Cancer # Central post-stroke pain
Lidocaine
Gabapentin
Duloxetine
Opioids
C.N.S.