TRIP

Treatment considerations for patients with neuropathic pain and other medical comorbidities.

Mayo Clinic Proceedings, 2010

maija.haanpaa@hus.fi The efficacy of drugs for neuropathic pain has been established in randomized controlled trials that have excluded patients with comorbid conditions and those taking complex medications.
However, patients with neuropathic pain frequently present with complex histories, making direct application of this evidence problematic.
Treatment of neuropathic pain needs to be individualized according to the cause of the pain, concomitant diseases, medications, and other individual factors.
Tricyclic antidepressants (TCAs), gabapentinoids, selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line choices; if needed, combination therapy may be used.
They should be avoided or used cautiously in patients with cardiac conduction disturbances or arrhythmias.
Patients who lack cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine and have a weaker analgesic response to tramadol.
Risk of gastrointestinal tract bleeding is increased in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially when combined with nonsteroidal anti-inflammatory drugs.
Particular care must be exercised during the first trimester when drug dose should be as low as possible.