What are the management options for postherpetic neuralgia (PHN) pain?

From the Guidelines

Post-shingles pain management should prioritize a multi-faceted approach, starting with topical lidocaine 5% patches or capsaicin 8% patches, and oral medications such as gabapentin or pregabalin, with tricyclic antidepressants like amitriptyline used cautiously in older adults. The most recent and highest quality study 1 recommends the use of anticonvulsants like gabapentin (300mg initially, gradually increasing to 1800-3600mg daily in divided doses) or pregabalin (75mg twice daily, increasing to 150-300mg twice daily as needed) as first-line treatments for postherpetic neuralgia (PHN). Some key points to consider when managing post-shingles pain include:

• Topical lidocaine 5% patches applied to the painful area for 12 hours daily, or capsaicin 8% patches applied by healthcare providers for 30-60 minutes every three months can be effective for localized pain relief.
• Oral medications such as gabapentin or pregabalin can help reduce nerve hyperexcitability and are often used as first-line treatments.
• Tricyclic antidepressants like amitriptyline (10-25mg at bedtime, gradually increasing to 75-150mg) can be effective but should be used cautiously in older adults due to potential side effects, as noted in a study from 1.
• Non-pharmacological approaches, including TENS units, physical therapy, and psychological interventions like cognitive behavioral therapy, can help improve function and coping.
• Treatment should be individualized based on pain severity, comorbidities, and response to therapy, with regular reassessment to optimize pain control while minimizing side effects, as recommended in 1 and 1.

From the FDA Drug Label

Clinical Studies 14. 1 Postherpetic Neuralgia Gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies. 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) The efficacy of pregabalin for the management of postherpetic neuralgia was established in three double-blind, placebo-controlled, multicenter studies Treatment with pregabalin statistically significantly improved the endpoint mean pain score and increased the proportion of patients with at least a 50% reduction in pain score from baseline

Post-shingles pain management can be achieved with:

• Gabapentin: initial dose of 300 mg on Day 1,600 mg/day on Day 2, and 900 mg/day on Day 3, titrated up to 1800 mg/day as needed 2
• Pregabalin: doses of 75,150, and 300 mg twice daily, or 100 and 200 mg three times a day, with treatment lasting 8-13 weeks 3 Key points:
• Gabapentin and pregabalin have been shown to be effective in reducing postherpetic neuralgia pain
• Doses should be titrated based on patient response and renal function
• Treatment should be individualized to each patient's needs 2, 3

From the Research

Post-Shingles Pain Management

• Post-herpetic neuralgia (PHN) is a chronic neuropathic pain condition that persists 3 months or more following an outbreak of shingles 4
• Patients with PHN may experience multiple types of pain, including constant deep, aching, or burning pain, paroxysmal, lancinating pain, hyperalgesia, and allodynia 4
• The pharmacological treatment of PHN may include a variety of medications, such as:
  • Alpha-2 delta ligands (gabapentin and pregabalin)
  • Other anticonvulsants (carbamazepine)
  • Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin)
  • Topical analgesics (5% lidocaine patch, capsaicin)
  • Tramadol or other opioids 4

Gabapentin for PHN

• Gabapentin has been shown to be effective in reducing PHN pain and improving sleep interference 5, 6
• The recommended dosage of gabapentin for PHN is 300 mg at bedtime on day 1,300 mg twice daily on day 2, and 300 mg three times daily on day 3, titrating up as needed to 2400 to 3600 mg/day 6
• Gabapentin has been compared to other formulations, such as extended-release gabapentin and gabapentin enacarbil, in terms of efficacy and safety for PHN treatment 7

Other Treatment Options

• Other orally administered therapies that have been shown to be effective for PHN include tricyclic antidepressants, "strong" opioids, tramadol, and pregabalin 8
• Topical therapies associated with efficacy for PHN include lidocaine 5% patch and capsaicin 8
• Spinal intrathecal administration of lidocaine and methylprednisolone has also demonstrated efficacy for PHN, although this has yet to be replicated 8