Managing Chronic Pain: Practical Considerations to Improve Treatment Outcomes - Episode 16

Treating Postherpetic Neuralgia: Weighing Patient Characteristics and Medication Options

Continuing the discussion on the treatment of shingles and postherpetic neuralgia, the panelists review some of the patient characteristics that should be considered when devising a treatment regimen.

Vitaly Gordin, MD, who works at a tertiary medical center, says he often sees patients with postherpetic neuralgia who have previously been treated with “medications from the gabapentinoid group, such as gabapentin or pregabalin.” He says he also frequently sees patients “who have been tried on topicals, typically the 5% lidocaine patch.”

Gordin says that not all treatments are appropriate for all patients, citing as examples an elderly woman who lives alone and might find it difficult to apply the Lidoderm patch, and an elderly man whose benign prostatic hypertrophy makes him a poor candidate for treatment with tricyclic antidepressants, which can cause orthostatic hypotension and urinary retention.

He also says the patient’s insurance status and ability to pay for medications is another factor that should be considered when making treatment decisions.

Switching gears slightly, moderator Jeffrey Gudin, MD, asks the panelists if they think venlafaxine is as effective as duloxetine for the treatment of neuropathic pain, and whether they have seen any data on patients who can’t get one drug using another with an SNRI-like mechanism of action.

Charles Argoff, MD, notes there was a study published several years ago on the benefit of venlafaxine for diabetic neuropathy. Unlike duloxetine, “which at any dose is a dual reuptake inhibitor of serotonin and norepinephrine,” venlafaxine at lower doses acts “primarily as a serotonin specific reuptake inhibitor,” Argoff says. He notes that the study on venlafaxine for diabetic neuropathy and a separate migraine headache study “demonstrated that unless you’re at a dose of 150 mg or above, you don’t get the analgesic benefit because it’s at that dose that it becomes a dual reuptake inhibitor.”