Stepped Care Drugs for Neuropathic Pain

Peripheral Neuropathy/Postherpetic Neuralgia (PHN)

*2017 ADA Guidelines recommend starting with pregabalin or duloxetine for diabetic peripheral neuropathy, and avoiding opioids.

• Lidocaine patch: 5% 1-3 patches 12h on/12h off – PHN only.
• Gabapentin: For younger pts. with normal CLcr: Day 1: 300mg, Day 2: 300mg BID, Day3: 300mg TID, then titrate to pain relief (max 3600 mg/d). Older adults: 100 mg qhs, titrate by 100 mg q week. Renal dosing maximum: CLcr 30-59: 600 mg bid; CLcr 15-20: 300 mg bid; CLcr<15: 300 mg qd. Supplement post dialysis.
• Pregabalin: 25-50 mg qhs; increase 25-50 mg q7d to 100 mg bid; max 300 mg qd. Renal dosing: CLcr 30-60: 150-300 mg/d; CLcr 15-30: 75-150 mg/d; CLcr <15: 25-50 mg/d. Supplement dose after dialysis.
• Venlafaxine: 37.5 mg/d; increase by 37.5 mg q week to 150 mg/d. Max 225 mg/d.
• Duloxetine: 20-30 mg/d; increase to 60 mg/d in 7d. Not recommended in ESRD or CLcr< 30.
• Nortriptyline or desipramine 10 mg qhs; increase 10 mg q7d to max of 50 mg qhs. Watch for QT prolongation; EKG prior to starting in older adults.
• Add or substitute opioids (dose per nociceptive pain) add if some effect with other drugs; substitute if no effect with other drugs.

Trigeminal neuralgia

• Carbamazepine: Start at 50 mg q week; titrate 50 mg q week to 100 mg bid. Max 1,200 mg/d. In patients who are Chinese, Thai, or Malaysian, consider testing for HLA-B* 1502 allele. If present, increased risk of toxic epidermal necrolysis and Stevens-Johnson syndrome.
• Gabapentin: if CBZ not tolerated (see PHN dose).
• Add baclofen if needed (not in older adults).