From the Guidelines
Post-herpetic neuralgia (PHN) treatment should typically involve a multimodal approach focusing on pain relief, with first-line medications including anticonvulsants such as gabapentin or pregabalin, as well as tricyclic antidepressants like amitriptyline, according to the most recent and highest quality study 1.
Treatment Approach
The treatment approach for PHN involves a combination of pharmacological and non-pharmacological interventions.
- First-line medications include:
- Anticonvulsants: gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) or pregabalin (starting at 75mg twice daily, increasing to 150-300mg twice daily) 1
- Tricyclic antidepressants: amitriptyline (10-25mg at bedtime, gradually increasing to 75-150mg)
- Topical treatments:
- Lidocaine 5% patches applied to the painful area for 12 hours daily
- Capsaicin 8% patches applied by healthcare providers can provide localized relief 1
Considerations
When considering treatment options, it is essential to weigh the potential benefits and risks of each medication, including the risk of addiction with opioids like tramadol or oxycodone 1.
- Combination therapy often works better than monotherapy
- Treatment duration varies, but PHN may require months of management, with gradual dose tapering once pain improves
- Non-pharmacological approaches like physical therapy, transcutaneous electrical nerve stimulation (TENS), and psychological support can complement medication therapy
Monitoring and Adjustment
Regular follow-up is essential to monitor efficacy and adjust treatment as needed, taking into account the patient's response to treatment and any potential side effects 1.
- Reassess pain and health-related quality of life frequently
- If substantial pain relief is achieved, continue treatment; if partial pain relief is achieved, consider adding another first-line medication; if no or inadequate pain relief is achieved, switch to an alternative first-line medication or consider referral to a pain specialist or multidisciplinary pain center 1
From the FDA Drug Label
Gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies. The intent-to-treat (ITT) population consisted of a total of 563 patients with pain for more than 3 months after healing of the herpes zoster skin rash Both studies demonstrated efficacy compared to placebo at all doses tested The reduction in weekly mean pain scores was seen by Week 1 in both studies, and was maintained to the end of treatment.
Treatment for Postherpetic Neuralgia:
- Gabapentin is effective for the management of postherpetic neuralgia (PHN) as demonstrated in two randomized, double-blind, placebo-controlled, multicenter studies 2.
- Pregabalin is also effective for the management of postherpetic neuralgia as established in three double-blind, placebo-controlled, multicenter studies 3.
- The studies show that both gabapentin and pregabalin can reduce pain scores in patients with PHN, with some patients experiencing a decrease in pain as early as Week 1.
- Key points to consider when treating postherpetic neuralgia include:
- Starting with a low dose and titrating up to an effective dose
- Monitoring for adverse reactions, particularly with higher doses
- Considering renal function when dosing pregabalin
- Using a pain rating scale to assess treatment efficacy
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
- The initial dosing strategy for gabapentin can start with 600 mg/day, which has been found to be safe and effective with minimal side effects 4
- Other treatment options include alpha-2 delta ligands (pregabalin), tricyclic antidepressants (amitriptyline, nortriptyline, doxepin), topical analgesics (5% lidocaine patch, capsaicin), tramadol, and opioids 5
- A once-daily extended-release formulation of gabapentin (Gralise) has been developed, which provides comparable drug exposure to the immediate-release formulation and has been shown to be effective in reducing average daily pain intensity scores 6
Pharmacological Management
- Amitriptyline, nortriptyline, desipramine, and imipramine are tricyclic antidepressants that have been shown to be effective for the symptomatic relief of post-herpetic neuralgia and painful diabetic neuropathy 7
- Serotonin noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine have been shown to be effective for the treatment of painful diabetic neuropathy 7
- Alpha2delta ligands such as gabapentin and pregabalin have been proven to be effective for the treatment of post-herpetic neuralgia and painful diabetic neuropathy 7
- Topical agents such as lidocaine 5% patches and topical capsaicin are useful in ameliorating pain in patients with post-herpetic neuralgia, but are often used in combination with other treatments 7, 8
Guidelines for Care
- Current guidelines recommend first-line treatments for post-herpetic neuralgia to include tricyclic antidepressants, gabapentin, and pregabalin, and the topical lidocaine 5% patch 8
- Opioids, tramadol, capsaicin cream, and the capsaicin 8% patch are recommended as either second- or third-line therapies in different guidelines 8
- Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of post-herpetic neuralgia, mainly in patients refractory to noninvasive pharmacologic interventions 8