From the Guidelines
Post-herpetic neuralgia (PHN) is best treated with a multimodal approach, starting with first-line medications like gabapentinoids (gabapentin 300-1200 mg three times daily or pregabalin 150-300 mg twice daily) or tricyclic antidepressants (amitriptyline 10-75 mg at bedtime). The treatment of PHN should prioritize medications with the strongest evidence for efficacy, which includes gabapentinoids and tricyclic antidepressants 1.
First-Line Treatments
- Gabapentinoids: gabapentin 300-1200 mg three times daily or pregabalin 150-300 mg twice daily
- Tricyclic antidepressants: amitriptyline 10-75 mg at bedtime These medications have been shown to be effective in reducing pain in patients with PHN, with gabapentinoids having a number needed to treat (NNT) of 4.39 and tricyclic antidepressants having an NNT of 2.64 1.
Topical Treatments
- Lidocaine 5% patches applied to the painful area for 12 hours daily
- Capsaicin 8% patches applied by healthcare providers for 30-60 minutes every 3 months Topical treatments are also effective and have fewer systemic side effects, making them a good option for patients who cannot tolerate oral medications or have significant comorbidities 1.
Combination Therapy
For patients with inadequate relief, combination therapy using medications with different mechanisms of action is recommended. This approach can provide additive beneficial effects or reduce adverse effects associated with single medication use 1.
Second-Line Options
- Tramadol (50-100 mg every 4-6 hours)
- Opioids for severe, refractory cases, though these should be used cautiously due to addiction potential Second-line options should be considered for patients who do not respond to first-line treatments, but their use should be carefully weighed against potential risks and benefits 1.
Treatment Duration and Dose Adjustment
Treatment typically continues for 4-6 weeks before assessing efficacy, and successful regimens should be maintained for 2-3 months before attempting gradual dose reduction. Elderly patients and those with compromised immune systems may require dose adjustments due to altered pharmacokinetics or increased sensitivity to medication side effects 1.
Non-Pharmacological Approaches
Non-pharmacological approaches like physical therapy, TENS units, and psychological support can complement medication management for this often challenging neuropathic pain condition. These approaches can help improve pain management, reduce disability, and enhance quality of life for patients with PHN 1.
From the FDA Drug Label
In adults with postherpetic neuralgia, gabapentin may be initiated on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg two times a day), and on Day 3 as 900 mg/day (300 mg three times a day). The dose can subsequently be titrated up as needed for pain relief to a dose of 1800 mg/day (600 mg three times a day) Gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies. The efficacy of pregabalin for the management of postherpetic neuralgia was established in three double-blind, placebo-controlled, multicenter studies
The treatment of postherpetic neuralgia can be managed with gabapentin or pregabalin.
- Gabapentin can be initiated at a dose of 300 mg on Day 1 and titrated up to 1800 mg/day as needed for pain relief 2.
- Pregabalin has been shown to be effective in the management of postherpetic neuralgia in three double-blind, placebo-controlled, multicenter studies 3. Key points:
- Gabapentin and pregabalin are effective treatments for postherpetic neuralgia.
- The dose of gabapentin can be titrated up to 1800 mg/day as needed for pain relief.
- Pregabalin has been shown to be effective in the management of postherpetic neuralgia in multiple studies.
From the Research
Treatment Options for Post Herpetic Neuralgia
- Gabapentin has been shown to provide pain relief for post-herpetic neuralgia at a dosage of 1200 to 2400 mg/day 4
- A once-daily extended-release formulation of gabapentin, Gralise, has been developed and shown to provide comparable drug exposure with an identical daily dose of the immediate-release formulation when administered three times daily 5
- Other treatment options include tricyclic antidepressants, pregabalin, lidocaine patches, and capsaicin 6, 7
- Interventional therapies such as transcutaneous electrical nerve stimulation, local botulinum toxin A injection, and stellate ganglion block may also be effective for patients who do not respond to conservative options 6
Comparison of Gabapentin and Pregabalin
- A retrospective cohort study found that pregabalin was more effective than gabapentin in the treatment of postherpetic neuralgia, with significantly higher clinical effectiveness and shorter time to pain relief 8
- However, the overall incidence of adverse events was equivalent between the two groups 8
Efficacy of Different Therapies
- A systematic review and meta-analysis found that tricyclic antidepressants, strong opioids, gabapentin, tramadol, and pregabalin were effective in reducing pain in postherpetic neuralgia 7
- Topical therapies such as lidocaine 5% patch and capsaicin were also found to be effective 7
- Certain therapies, such as NMDA receptor antagonists and codeine, were not found to be effective in reducing pain in postherpetic neuralgia 7