What treatment options are available for constant burning and aching sensations?

Treatment for Constant Burning and Aching Sensations

For constant burning and aching pain, start with gabapentin 100-300 mg at bedtime, titrating up to 900-3600 mg daily in divided doses, as this is the first-line pharmacological treatment for neuropathic pain with the strongest evidence base. 1

Initial Assessment and Pain Characterization

Before initiating treatment, determine if the burning and aching sensations are:

• Neuropathic in origin (sharp, tingling, shooting, burning quality suggesting nerve damage) 1
• Localized or widespread (affects treatment selection between topical vs systemic agents) 1
• Associated with specific conditions (postherpetic neuralgia, diabetic neuropathy, cancer-related pain) 1

First-Line Pharmacological Treatment: Gabapentinoids

Gabapentin Dosing Protocol

• Start low: Begin with 100-300 mg once daily at bedtime (use 100 mg in elderly or renally impaired patients) 1, 2
• Titrate gradually: Increase by 100-300 mg every 3-5 days as tolerated 1
• Target dose: 900-1800 mg daily divided into 2-3 doses provides substantial benefit for most patients 1, 2, 3
• Maximum dose: Up to 3600 mg daily in divided doses may be needed for refractory cases 1, 2, 3
• Evidence: 32-38% of patients achieve at least 50% pain relief compared to 17-21% with placebo (NNT 5.9-6.7) 3

Pregabalin as Alternative

If gabapentin is not tolerated or ineffective:

• Start: 25-50 mg daily (lower dose for elderly or renal impairment) 1
• Titrate: Increase every 3-5 days 1
• Target dose: 150-300 mg daily in 2 divided doses 1
• Maximum: 600 mg daily 1, 4
• Advantage: More predictable absorption and easier titration than gabapentin 1

Common side effects to monitor: Somnolence (14%), dizziness (19%), peripheral edema (7%), gait disturbance (14%) - typically mild to moderate and subside within 10 days 2, 3

Second-Line Options if Inadequate Response to Gabapentinoids

Antidepressants

Tricyclic antidepressants (if no cardiac contraindications):

• Nortriptyline or desipramine preferred (better tolerated than amitriptyline) 1
• Start: 10-25 mg nightly 1
• Titrate: Increase every 3-5 days up to 14 days 1
• Target: 50-150 mg nightly 1

SNRIs (serotonin-norepinephrine reuptake inhibitors):

• Duloxetine: Start 30-60 mg daily 1
• Venlafaxine: Start 50-75 mg daily, increase to 75-225 mg daily 1

Topical Treatments for Localized Pain

First-Line Topical Agents

Lidocaine 5% patch:

• Apply daily to painful site 1, 5, 6
• Minimal systemic absorption, excellent safety profile 1, 5
• Can cut patches to fit affected area, use up to 3 patches simultaneously 6

High-concentration capsaicin (8% patch):

• Single 30-minute application provides relief for up to 12 weeks 1
• Apply 4% lidocaine for 60 minutes before capsaicin to reduce initial burning 1
• Expect initial burning/stinging that subsides with continued use 6

Topical NSAIDs (diclofenac gel/patch):

• Apply 3 times daily for inflammatory pain 1, 5, 6
• Preferred in elderly due to reduced systemic adverse effects 1, 5

Combination Therapy Approach

When monotherapy provides insufficient relief:

• Combine gabapentinoid with topical agent (lidocaine patch or capsaicin) 1, 5
• Add antidepressant to gabapentinoid for synergistic effect 1
• Consider alpha lipoic acid 600 mg daily as adjunct (particularly for neuropathic pain) 1

Non-Pharmacological Interventions

Cognitive behavioral therapy: Strongly recommended for chronic pain management, promotes adaptive behaviors and addresses maladaptive pain responses 1

Physical therapy: Recommended for maintaining function and reducing pain 1

Hypnosis: Specifically recommended for neuropathic pain 1

Special Considerations and Pitfalls

Renal Impairment

• Dose adjustment mandatory for gabapentin and pregabalin in patients with creatinine clearance <60 mL/min 1, 4
• Patients with CrCl 30-60 mL/min tolerate gabapentinoids less well with higher discontinuation rates 4

Elderly Patients

• Start with lowest doses: Gabapentin 100-200 mg/day or pregabalin 25-50 mg/day 1
• Slower titration: Extend intervals between dose increases 1
• Monitor closely: Higher risk of somnolence, dizziness, mental clouding 1

Avoid Common Mistakes

• Do not start gabapentin at 300 mg three times daily - this causes excessive side effects and poor adherence 1, 2
• Do not discontinue prematurely - analgesic effect may take 1-2 weeks to manifest fully 2, 3
• Do not use lamotrigine - proven ineffective for neuropathic pain 1
• Do not use neuroleptics - limited efficacy with significant adverse effects in older adults 1

Treatment Timeline

• Week 1: Pain relief may begin as early as first week 4, 2
• Weeks 2-4: Continue titration until benefit occurs or side effects limit further increase 1
• Reassess at 4-8 weeks: If inadequate response, add second agent or switch to alternative 1, 6