Management of Paresthesia Neuralgia
First-line treatment for paresthesia neuralgia should include either duloxetine (30 mg/day for 1 week, then 60 mg/day) or tricyclic antidepressants such as nortriptyline (starting at 10-25 mg at bedtime and titrating to 25-100 mg) based on the highest quality evidence. 1, 2
Pharmacological Management Algorithm
First-Line Medications:
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
- Duloxetine: Start at 30 mg/day for 1 week, then increase to 60 mg/day
- Venlafaxine: Start at 50 mg initially, followed by 37.5 mg twice daily
- Evidence level: I, B for duloxetine; II, C for venlafaxine 2
Tricyclic Antidepressants (TCAs)
Second-Line Medications:
- Anticonvulsants
- Pregabalin: Start at 75 mg twice daily, titrate to 300-600 mg/day 1, 3
- Gabapentin: Start at 100-300 mg at bedtime, titrate to 900-3600 mg/day in divided doses 1, 4
- Carbamazepine: Start at 200 mg at night, gradually increase by 200 mg every 7 days to 400-1200 mg/day in 2-3 divided doses 2
- Evidence level: II, C-D for pregabalin/gabapentin; Level A for carbamazepine in trigeminal neuralgia 2
Third-Line Medications:
- Opioids
Topical Treatments:
- Topical options
- Lidocaine patches: For localized pain
- Capsaicin patches (8%): Applied for 30-60 minutes on affected regions
- Topical menthol cream (1%): Applied twice daily to affected area
- Evidence level: I, C to III, B 2
Dosing Adjustments for Special Populations
Renal Impairment
Pregabalin dose adjustment:
Creatinine Clearance (mL/min) Total Daily Dose Range (mg/day) ≥60 300-600 30-59 150-300 15-29 75-150 <15 25-75 Gabapentin: Requires similar dose adjustments based on creatinine clearance 4, 5
Elderly Patients
- Start at lower doses and titrate more slowly 1
- Monitor for side effects more frequently
Non-Pharmacological Interventions
- Cognitive Behavioral Therapy: Helps manage pain perception and coping strategies 1
- Transcutaneous Electrical Nerve Stimulation (TENS): May provide relief for some patients 1
- Physical therapy and progressive resistance training: Can improve function and reduce pain 1
- Interventional techniques: Consider nerve blocks or intrathecal drug delivery for refractory cases 2
Monitoring and Follow-up
- Assess pain reduction using a numerical pain rating scale (0-10)
- Monitor for common side effects:
- TCAs: Anticholinergic effects (dry mouth, constipation), sedation, cardiac conduction abnormalities
- SNRIs: Nausea, dizziness, somnolence, hypertension
- Anticonvulsants: Dizziness, somnolence, peripheral edema, weight gain 1
- Obtain ECG before starting TCAs in patients with cardiovascular disease 1
- Follow up within 2-4 weeks to assess efficacy and side effects
Common Pitfalls to Avoid
- Inadequate dosing: Ensure proper titration to effective doses before concluding treatment failure 1
- Premature discontinuation: Therapeutic effects may take several days to weeks to manifest 1
- Monotherapy fixation: Many patients benefit from combination therapy (e.g., anticonvulsant + antidepressant) 1
- Overlooking cardiac risk with TCAs: Particularly important in elderly patients or those with cardiovascular disease 1
- Failure to adjust doses in renal impairment: Can lead to toxicity with gabapentin and pregabalin 1, 5
Special Considerations
- For neuropathic pain due to bone metastases, consider radiation therapy at 20 Gy in five fractions 2
- For chemotherapy-induced peripheral neuropathy, duloxetine shows better efficacy in platinum-based therapy than in taxanes 2
- Early pain management is crucial to prevent central sensitization and chronic pain development 2