A patient with multiple sclerosis, stable on teriflunomide, denies neurological symptoms but reports generalized body pain; which medication should be added to her regimen?

Management of Generalized Body Pain in Multiple Sclerosis

For a patient with well-controlled MS on teriflunomide presenting with generalized body pain and no neurological symptoms, initiate treatment with gabapentin or pregabalin as first-line therapy, starting with gabapentin 300 mg on day 1,600 mg on day 2, then 900 mg/day on day 3, titrating up to 1800-3600 mg/day in divided doses based on response. 1, 2

First-Line Pharmacologic Approach

The American Academy of Neurology recommends calcium channel α2-δ ligands (gabapentin or pregabalin) as first-line treatment for neuropathic pain in multiple sclerosis, with moderate to high strength of evidence. 1

Gabapentin dosing:

• Start at 300 mg once daily, increase to 600 mg on day 2, then 900 mg/day on day 3
• Titrate up to 1800-3600 mg/day in three divided doses based on response and tolerability
• Allow 2-4 weeks at therapeutic doses to properly assess efficacy 2

Pregabalin alternative:

• Start at 150 mg/day in 2-3 divided doses
• Increase to 300 mg/day after 1 week
• Maximum dose 600 mg/day
• Offers faster pain relief than gabapentin due to linear pharmacokinetics 2

The most common side effects are somnolence, dizziness, and weight gain. 3

Second-Line Options if Inadequate Response

If gabapentinoids provide insufficient relief after 2-4 weeks at therapeutic doses, add or switch to duloxetine (SSNRI) 30 mg once daily for 1 week, then increase to 60 mg once daily. 1, 2 Duloxetine has demonstrated moderate clinical benefit in neuropathic pain with a number needed to treat of 5.2 and can be increased to 120 mg/day if needed. 2

Alternatively, tricyclic antidepressants such as nortriptyline or desipramine are effective for MS-related neuropathic pain, though they have more anticholinergic side effects and require ECG screening in patients over 40 years old before initiation. 1, 2

Critical Evaluation Points

Before initiating treatment, establish:

• The specific type of pain syndrome (neuropathic vs. musculoskeletal vs. central pain)
• Whether pain is localized or diffuse
• Presence of allodynia, hyperalgesia, or dysesthesia suggesting neuropathic origin
• Any triggers or exacerbating factors 1

Red flags requiring urgent evaluation:

• New neurological deficits suggesting MS relapse
• Sensory deficits in specific distributions
• Continuous severe pain with autonomic features
• Signs of infection or other systemic illness 3, 4

Why Not the Other Options?

Tizanidine (Option A): This skeletal muscle relaxant is indicated for spasticity, not generalized pain without neurological symptoms. The evidence for skeletal muscle relaxants in chronic pain is insufficient, and there is no spasticity described in this patient. 3

Oxybutynin (Option C): This anticholinergic medication is used for bladder dysfunction in MS, not pain management. The patient denies neurological symptoms and has no indication for bladder-specific therapy. 3

Carbamazepine (Option D): While carbamazepine is the primary drug of choice for trigeminal neuralgia in MS patients, it is specifically indicated for paroxysmal, sharp, shooting facial pain—not generalized body pain. 3, 1, 4 This patient's presentation of generalized body pain without the characteristic lancinating quality or facial distribution makes carbamazepine inappropriate.

Monitoring and Follow-Up

• Assess pain relief after 2-4 weeks at therapeutic doses before declaring treatment failure 2
• Monitor for common side effects: dizziness, somnolence, peripheral edema with gabapentinoids 3
• Consider adding physical exercise and functional training as adjunctive therapy, which can provide anti-inflammatory effects and improve pain perception 2
• Avoid NSAIDs as there is no data supporting their benefit in neuropathic pain 2

Practical Considerations with Teriflunomide

The patient's current teriflunomide therapy for MS is well-tolerated and effective for disease modification, with no significant drug interactions with gabapentinoids or SNRIs. 5, 6, 7 Continue teriflunomide while adding pain management therapy, as there is no contraindication to combination treatment.