What is the recommended treatment for postherpetic neuralgia?

From the Guidelines

The recommended treatment for postherpetic neuralgia is a multimodal approach, with first-line medications including anticonvulsants such as gabapentin or pregabalin, as supported by the most recent and highest quality study 1. The treatment typically involves a combination of medications with different mechanisms of action, including:

• Anticonvulsants: gabapentin starting at 300mg daily and titrating up to 1800-3600mg daily in divided doses, or pregabalin 150-600mg daily in divided doses, as recommended by 1
• Topical agents: lidocaine 5% patch applied to the affected area for 12 hours daily, or capsaicin 8% patch applied by healthcare professionals, as supported by 1 For patients with inadequate relief, opioid analgesics may be considered as second or third-line options, though their long-term use carries risks of dependence and side effects, as noted in 1. Non-pharmacological approaches including physical therapy, transcutaneous electrical nerve stimulation (TENS), and psychological interventions like cognitive behavioral therapy can complement medication management, as suggested by 1. Treatment should be individualized based on patient characteristics, comorbidities, and potential drug interactions, and typically continues for months, with periodic reassessment of efficacy and side effects, and gradual dose reduction attempts once pain is controlled for an extended period. Key considerations in treatment include:
• Individualizing treatment based on patient characteristics and comorbidities
• Using combination therapy to achieve better pain control
• Monitoring for potential side effects and drug interactions
• Incorporating non-pharmacological approaches to complement medication management.

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)

The recommended treatment for postherpetic neuralgia is gabapentin, which 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.

• The dose can be increased to 600 mg/day on Day 2 and 900 mg/day on Day 3.
• Pregabalin is also an option for the management of postherpetic neuralgia, with doses ranging from 75 to 300 mg twice daily, depending on renal function 3.
• Key considerations for treatment include:
  • Initiating treatment with a low dose and titrating up as needed
  • Monitoring renal function and adjusting the dose accordingly
  • Considering alternative treatments if the patient does not respond to initial therapy

From the Research

Treatment Options for Postherpetic Neuralgia

The treatment for postherpetic neuralgia (PHN) typically involves a combination of medications and interventional therapies. Some of the recommended treatment options include:

• Gabapentin: a medication that has been shown to provide pain relief for PHN at dosages of 1200 to 2400 mg/day 4
• Pregabalin: a medication that has been found to be effective in relieving pain and improving sleep in patients with PHN, with a recommended dosage of 150-600 mg/day 5
• Tricyclic antidepressants: medications such as amitriptyline, nortriptyline, and doxepin that can help alleviate pain and other symptoms of PHN 6
• Topical analgesics: such as 5% lidocaine patch and capsaicin cream, which can be used to relieve pain and other symptoms of PHN 6
• Interventional therapies: such as transcutaneous electrical nerve stimulation, local botulinum toxin A injection, and stellate ganglion block, which can be used to relieve pain and other symptoms of PHN 7

Dosage and Administration

The dosage and administration of these medications and therapies can vary depending on the individual patient and the severity of their symptoms. For example:

• Gabapentin can be started at a dose of 600 mg/day and titrated up to 1200 to 2400 mg/day as needed 4
• Pregabalin can be started at a dose of 150 mg/day and titrated up to 600 mg/day as needed 5
• Gralise, a once-daily extended-release formulation of gabapentin, can be started at a dose of 1800 mg/day and titrated up to 3600 mg/day as needed 8

Considerations for Treatment

When treating PHN, it is essential to consider the individual patient's response to treatment and adjust the dosage and administration of medications and therapies accordingly. Additionally, physicians and other treatment providers must be aware of the potential side effects of these medications and therapies and monitor patients closely for any adverse reactions 7, 6