The efficacy of drugs for neuropathic pain has been established in randomized controlled
trials that have excluded patients with comorbid conditions and those taking complex
medications. However, patients with neuropathic pain frequently present with complex
histories, making direct application of this evidence problematic. Treatment of neuropathic
pain needs to be individualized according to the cause of the pain, concomitant diseases,
medications, and other individual factors. Tricyclic antidepressants (TCAs), gabapentinoids,
selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line
choices; if needed, combination therapy may be used. When a new drug is added, screening
for potential drug interactions is recommended. The TCAs have anticholinergic adverse
effects and may cause orthostatic hypotension. They should be avoided or used cautiously
in patients with cardiac conduction disturbances or arrhythmias. Patients who lack
cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine
and have a weaker analgesic response to tramadol. A combination of several serotoninergic
drugs may lead to serotonin syndrome. Risk of gastrointestinal tract bleeding is increased
in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially
when combined with nonsteroidal anti-inflammatory drugs. Dose adjustment may be needed
in patients with renal or hepatic impairment. Depending on the drug, the dose is reduced
or the dosage interval lengthened. Slow titration and careful follow-up are needed.
No drug is absolutely safe during pregnancy and lactation. Particular care must be
exercised during the first trimester when drug dose should be as low as possible.
Individual weighing of benefits and risks should guide therapeutic decisions.
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Article info
Footnotes
Dr Haanpää has served as consultant for Boehringer Ingelheim, GlaxoSmithKline, Eli Lilly, Medtronic, MSD, Mundipharma, Orion, Pfizer, and Sanofi Pasteur and is a permanent assessor of EMEA. Drs Gourlay and Miaskowski have no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this supplement. Dr Kent has received grant/research support from GlaxoSmithKline and has served on the speakers' bureau for Medtronic. Dr Raja has received grant/research support from Allergan and Medtronic and has served as a consultant for Allergan, Schering-Plough, Solvay, and Alpharma (King). Dr Schmader has received grant/research support from Merck and Wyeth and has served as a consultant for Merck and GlaxoSmithKline. Dr Wells has served as a consultant for Prostrachan and is on the speakers' bureau for Grünenthal, NAPP (Purdue in the United States), and Pfizer.
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© 2010 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
