From the Guidelines
Gabapentin is recommended as a first-line oral pharmacological treatment for post-herpetic neuralgia, with a typical adult regimen titrating to 2400 mg per day in divided doses. This recommendation is based on the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1. The guideline suggests that gabapentin is effective in treating chronic HIV-associated neuropathic pain, and its use can be extended to post-herpetic neuralgia.
Some key points to consider when using gabapentin for post-herpetic neuralgia include:
- Gabapentin improves sleep scores, but somnolence is a common side effect, reported by 80% of patients who received gabapentin 1
- If patients have an inadequate response to gabapentin, clinicians might consider a trial of pregabalin, which is a precursor to gabapentin and has been found to be effective in treating post-herpetic neuralgia 1
- Topical treatments such as capsaicin 8% patches or lidocaine 5% patches can provide localized pain control and may be used in conjunction with gabapentin
It's worth noting that the evidence for gabapentin in post-herpetic neuralgia is strong, with a number needed to treat (NNT) of 4.39, indicating that gabapentin is an effective treatment option for this condition 1. Overall, gabapentin is a recommended first-line treatment for post-herpetic neuralgia, due to its efficacy and relatively favorable side effect profile.
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) In clinical studies, efficacy was demonstrated over a range of doses from 1800 mg/day to 3600 mg/day with comparable effects across the dose range; however, in these clinical studies, the additional benefit of using doses greater than 1800 mg/day was not demonstrated.
The recommended treatment for post-herpetic 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.
- The dose can be increased to 600 mg/day on Day 2 and 900 mg/day on Day 3.
- Clinical studies have demonstrated efficacy at doses ranging from 1800 mg/day to 3600 mg/day, but the additional benefit of using doses greater than 1800 mg/day was not demonstrated 2.
From the Research
Treatment Options for Post-Herpetic Neuralgia
- Post-herpetic neuralgia (PHN) is a chronic neuropathic pain condition that persists 3 months or more following an outbreak of shingles 3.
- The pharmacological treatment of PHN may include a variety of medications, such as:
Gabapentin 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 5.
- A study suggests that 600 mg/day gabapentin could be a safe and effective starting dose for patients with post-herpetic neuralgia 5.
- Gabapentin is effective in reducing neuropathic pain due to post-herpetic neuralgia when given at least three times per day 6.
- A once-daily extended-release formulation of gabapentin (Gralise) has been developed, which provides comparable drug exposure with an identical daily dose of the immediate-release formulation when administered three times daily 6.
Other Treatment Options
- Interventional therapies, such as transcutaneous electrical nerve stimulation, local botulinum toxin A, cobalamin, and triamcinolone injection, may be valuable for patients who do not respond to conservative options 7.
- Tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline may be considered as a second-line option for patients with refractory pain 4.
- Spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia, although the evidence is limited 7.