From the Guidelines
Tramadol would not be considered a first-line treatment for postherpetic neuralgia (PHN). First-line treatments for PHN typically include anticonvulsants such as gabapentin (300-1200 mg three times daily) or pregabalin (75-300 mg twice daily), tricyclic antidepressants like amitriptyline (10-25 mg at bedtime, gradually increased), or topical agents such as lidocaine 5% patches (applied to the painful area for up to 12 hours daily) and capsaicin 8% patches (applied by healthcare professionals) 1.
According to the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV, analgesic efficacy was observed for tricyclic antidepressants, certain opioids, gabapentin, pregabalin, and topical lidocaine patches, but tramadol had a higher number needed to treat (NNT) compared to other first-line options 1.
The preference for non-opioid medications like gabapentin, pregabalin, and amitriptyline stems from their better safety profile and evidence supporting their effectiveness specifically for neuropathic pain conditions like PHN, which results from nerve damage following a herpes zoster (shingles) infection 1.
Key points to consider when treating PHN include:
- Starting with first-line treatments that have a better safety profile and evidence supporting their effectiveness
- Considering patient comorbidities and potential interactions with other medications
- Monitoring patients closely for adverse effects and adjusting treatment as needed
- Reserving opioids and other second-line treatments for patients who have not responded to first-line options or have severe pain that requires more intensive management 1.
In the context of PHN treatment, tramadol is not the preferred first-line option due to its lower efficacy and higher risk of adverse effects compared to other available treatments 1.
From the Research
Postherpetic Neuralgia Treatment
The treatment for postherpetic neuralgia (PHN) typically involves medication therapies. The following are common first-line treatments for PHN:
- Tricyclic antidepressants, such as amitriptyline 2
- Gabapentin and pregabalin, which are alpha2delta ligands 2, 3, 4
- Lidocaine patches, a topical therapy 2, 4
- Strong opioids, such as tramadol 2, 4
Medication Not Typically First-Line Treatment
Based on the provided evidence, the medication that would not be a first-line treatment for postherpetic neuralgia is:
- Tramadol (Ultram) is actually considered a second- or third-line therapy, according to 5. However, other sources 2, 4 list tramadol as an option for PHN treatment, but often after other medications have been tried.
It's essential to note that while tramadol is sometimes used for PHN, the first-line treatments usually include tricyclic antidepressants, gabapentin, pregabalin, and lidocaine patches, as supported by 5, 2, 3, 4. The choice of medication depends on various factors, including the patient's medical history, the severity of symptoms, and potential side effects.