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Treatment options in postherpetic neuralgia
Author(s) -
Bonezzi Cesare,
Demartini Laura
Publication year - 1999
Publication title -
acta neurologica scandinavica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.967
H-Index - 95
eISSN - 1600-0404
pISSN - 0001-6314
DOI - 10.1111/j.1600-0404.1999.tb07387.x
Subject(s) - postherpetic neuralgia , medicine , neuropathic pain , anesthesia , neuralgia , gabapentin , trigeminal neuralgia , tricyclic , pregabalin , pain ladder , pharmacology , opioid , alternative medicine , receptor , pathology
Postherpetic neuralgia (PHN) is a separate disease entity that represents a complication of acute herpes zoster. PHN, involving aberrant somatosen‐sory processing in the peripheral and/or central nervous system, is considered to be a chronic neuropathic pain, frequently unresponsive to all treatment modalities. Despite the clinical trial data demonstrating successful pain relief with several drug regimens, the pharmacologic management of neuropathic pain is difficult, particularly in PHN. Response to therapy is generally inhomogeneous. Some patients experience long‐term pain control with either topical or oral monotherapy with antidepressants, anticonvulsants, or opioids. Other PHN patients, such as those suffering pain due to central nervous system lesions, are extraordinarily refractory to all measures. This article will review current treatments ‐tricyclic antidepressants, anticonvulsants, local anesthetics, clonidine, N ‐methyl‐D‐aspartate (NMDA)‐antagonists, and opioids ‐ and focus on mechanism‐based pharmacologic interventions. Pharmacologic approaches can be classified into three groups: 1) drugs that act topically in the affected skin area; 2) drugs that act on nerve excitability and conduction in sensory axons; and 3) drugs that act on neural damage‐related synaptic changes. This last group is the only pain treatment option related to central denervation. To date, the treatment of PHN has relied on the use of tricyclic antidepressants (TCAs), which represent the most comprehensively studied medications for this pain syndrome. Clinical data indicate that TCAs are effective analgesics in approximately 50% of patients; these drugs have been recommended as first‐line agents for all neuropathic pain syndromes except trigeminal neuralgia, but are frequently contraindi‐cated or poorly tolerated in elderly patients with PHN. If monotherapy fails, a mechanism‐ and/or symptom‐based multidrug regimen can be used. There is also consistent support for intravenous and topical lido‐caine, intravenous ketamine, carbamazepine, and opioids. Gabapentin, a new anticonvulsant, can be considered a first‐line oral medication for PHN based on the efficacy and safety results of a recently completed double‐blind trial. In addition to positive effects on PHN, sleep, mood, and overall quality of life were significantly improved.