Neuropathic Pain Treatments

NEUROPATHIC PAIN TREATMENTS
Generic Brand Strength Form Adult Dose
DIABETIC PERIPHERAL NEUROPATHY
L-Methylfolate
L-methyl-
folate calcium, 
pyridoxal 5-phos-
phate, methylco-
balamin
Metanx 3mg/
 
35mg/
 
2mg
tabs 1−2 tabs daily
Opioid
tapentadol Nucynta 
ER
50mg, 100mg, 150mg, 200mg, 250mg ext-rel tabs 100−250mg twice daily; >500mg: Not recommended.
Opioid-naïve: Initially 50mg twice daily; then titrate to optimal dose within therapeutic range of 100−250mg twice daily.
Opioid conversion: See monograph.
Moderate hepatic impairment: Initially 50mg once daily; max 100mg once daily.
Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
duloxetine HCl Cymbalta 20mg, 
30mg, 60mg
e-c pellets in caps 60mg once daily; may start at lower doses.
Renal impairment: Consider lower starting dose and slow titration.
Topical Analgesic
capsaicin Zostrix 0.025% emol-
lient crm
Apply 3−4 times daily
Zostrix‑HP 0.075% emol-
lient crm
Apply 3−4 times daily
Alpha2-Delta Ligand
pregabalin Lyrica 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg caps Initially 50mg 3 times daily, may increase to 100mg 3 times daily within 1wk.
Renal impairment (CrCl <60mL/min): Reduce dose (see literature); hemodialysis: Give supplemental dose after session.
FIBROMYALGIA
Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)
duloxetine HCl Cymbalta 20mg, 30mg, 60mg e-c pellets in caps Initially 30mg once daily for 1wk, then increase to 60mg once daily.
milnacipran HCl Savella 12.5mg, 25mg, 50mg, 100mg tabs Day 1: 12.5mg once. Days 2−3: 12.5mg twice daily. Days 4−7: 25mg twice daily. After Day 7: 50mg twice daily (recommended dose); max 100mg twice daily.
Severe renal impairment (CrCl 5−29mL/min): Maintenance 25mg twice daily; max 50mg twice daily.
Alpha2-Delta Ligand
pregabalin Lyrica 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg caps Initially 75mg twice daily, may increase to 150mg twice daily within 1wk as tolerated; max 450mg/day.
Renal impairment (CrCl <60mL/min): Reduce dose (see literature); hemodialysis: Give supplemental dose after session.
POSTHERPETIC NEURALGIA
gabapentin Gralise 300mg, 600mg tabs Take once daily with the evening meal. ≥18yrs: initially 300mg on Day 1, 600mg on Day 2, 900mg on Days 3−6, 1200mg on Days 7−10, 1500mg on Days 11−14, titrate up to 1800mg on Day 15.
Renal impairment: CrCl 30−60mL/min: 600−1800mg. CrCl <30mL/min or on hemodialysis: Not recommended.
Neurontin 100mg, 300mg, 400mg caps 300mg once on day 1, twice daily on day 2, and 3 times daily on day 3; may titrate up to usual max 1.8g/day in 3 divided doses (doses up to 3.6g/day have been used without added benefit).
Renal dysfunction: CrCl 30−59mL/min: 400−1400mg/day twice daily; CrCl 15−29mL/min: 200−700mg once daily; CrCl ≤15mL/min: 100−300mg once daily (see literature); hemodialysis: 125−350mg after session.
600mg, 800mg scored tabs
250mg/
 
5mL
soln
gabapentin enacarbil Horizant 300mg, 600mg ext-rel tabs Initially 600mg in the AM for 3 days, then increase to 600mg twice daily beginning on Day 4 (no additional benefit seen with >1200mg daily dose).
Renal impairment: CrCl 30−59mL/min: initially 300mg in the AM for 3 days, then 300mg twice daily; may increase to 600mg twice daily if needed or tolerated. CrCl 15−29mL/min: 300mg in the AM on Day 1 and Day 3, then continue with 300mg in AM; may increase to 300mg twice daily if needed. CrCl <15mL/min: Maintenance: 300mg every other day in the AM, may increase to 300mg once daily if needed. CrCl <15mL/min on hemodialysis: Maintenance: 300mg after every session, may increase to 600mg if needed. Tapering doses: See literature.
Alpha2-Delta Ligand
pregabalin Lyrica 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg caps Initially 150mg/day in 2−3 divided doses; max 300mg/day after 1wk, then 600mg/day after 2wks as tolerated.
Renal impairment (CrCl <60mL/min): Reduce dose (see literature); hemodialysis: Give supplemental dose after session.
Topical Analgesic/Anesthetic
capsaicin Qutenza 8% (179mg) adhe-
sive patch
Pretreat with topical anesthetic to reduce discomfort, once anesthetized, remove anesthetic and wash the treatment area. Apply to dry, intact skin within 2hrs of opening patch. Apply patch (up to 4 may be used) for 60min, repeat every 3mos or as warranted by the return of pain (not more frequently than every 3mos). Treat acute pain during and following the procedure with local cooling and/or analgesics.
Zostrix 0.025% emol-
lient crm
Apply 3−4 times daily
Zostrix‑HP 0.075% emol-
lient crm
Apply 3−4 times daily
lidocaine Lidoderm 5% adhe-
sive patch
To adjust dose, cut patches before removing release liner. May apply up to 3 patches at once for up to 12hrs of a 24‑hr period.
Hepatic impairment or debilitated: Use smaller treatment areas.
SPINAL CORD INJURY
Alpha2-Delta Ligand
pregabalin Lyrica 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg caps Initially 75mg twice daily, may increase to 150mg twice daily in 1wk, then max 600mg/day after 2wks as tolerated.
Renal impairment (CrCl <60mL/min): Reduce dose (see literature); hemodialysis: Give supplemental dose after session.

(Rev. 8/2014)

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