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Post-herpetic neuralgia - Management
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What advice should I give about post-herpetic neuralgia?
- Explain that symptoms can resolve after a few months, or may persist for longer. Interventions may not completely resolve the pain, but may reduce it.
- Advise the person to:
- Wear loose clothing or cotton fabrics, as these will usually cause the least irritation.
- Consider protecting sensitive areas by applying a protective layer (e.g. cling film or a plastic wound dressing).
- Consider frequent application of cold packs (unless allodynia is triggered by cold).
Basis for recommendation
How should I treat post-herpetic neuralgia?
- Initiate treatment with paracetamol, either alone or in combination with codeine.
- If this is not effective, or the person presents with severe pain, consider offering amitriptyline (off-label use) or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin) for initial treatment.
- The choice of drug depends on the relative contraindications, possible drug interactions, and risk of adverse effects for each person.
- Titrate the dosage according to response and tolerability.
- For further information, on contraindications, cautions, managing adverse effects, and second-line options if amitriptyline or pregabalin are not effective, see the CKS topic on Neuropathic pain - drug treatment.
- Nonsteroidal anti-inflammatory drugs are not recommended because there is no evidence on their efficacy in postherpetic neuralgia.
Basis for recommendation
Recommended treatments
- The use of simple analgesia (paracetamol alone or in combination with codeine) is recommended in two guidelines on the management of shingles and post-herpetic neuralgia [BSSI, 1995; International Herpes Management Forum, 2002]. These drugs are commonly used, although CKS could find no good-quality evidence to support this.
- The recommendation to offer a trial course of amitriptyline or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin) is based on guidance issued by the National Institute for Health and Clinical Excellence on drug treatment of neuropathic pain in adults [NICE, 2010]. For further information, see the CKS topic on Neuropathic pain - drug treatment.
- Having reviewed the evidence for a number of neuropathic conditions (including post-herpetic neuralgia), the NICE guidance development group (GDG) treated the term 'neuropathic pain' as a blanket condition regardless of the underlying cause; the GDG considered this to be helpful and practical for non-specialist healthcare professionals and patients. However, condition-specific recommendations were made if robust evidence on clinical efficacy and cost-effectiveness existed (as in the case of painful diabetic neuropathy), or where the evidence was clearly uncertain and insufficient to alter current clinical practice (as in the case of trigeminal neuralgia). The GDG acknowledged that evidence for treating a particular neuropathic pain condition with a particular aetiology is often extrapolated to other neuropathic pain conditions with other aetiologies, although there is little evidence to support the validity of this [NICE, 2010].
Treatments not recommended
- A review by the International Herpes Management Forum found no evidence to support the use of nonsteroidal anti-inflammatory drugs in post-herpetic neuralgia [International Herpes Management Forum, 2002].
- Carbamazepine has evidence to support its use for neuropathic pain [Wiffen et al, 2005]. However, taking into account the lack of good-quality evidence specific to post-herpetic neuralgia, potentially serious adverse effects, and the lack of a license for this purpose, CKS has not recommended it as primary care treatment.
- CKS has not recommended strong opioids as an option in primary care even though limited evidence suggests they may be effective in reducing the pain associated with post-herpetic neuralgia [Wareham, 2006]. This is in view of their adverse effects profile and the fact that they are more commonly used in a specialist setting [International Herpes Management Forum, 2002].
When should I refer post-herpetic neuralgia?
- Refer to a pain clinic or seek specialist advice if:
- Advice and primary care treatment are not effective in controlling pain after 4–6 weeks.
- Adverse effects limit treatment.
- Strong opioids or carbamazepine are being considered.
Basis for recommendation
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Analgesia use when required
Age from 16 years onwards
Paracetamol tablets: 1g up to four times a day
Paracetamol 500mg tablets
Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Add on if severe pain: codeine tablets
Codeine 30mg tablets
Take one to two tablets every 4 to 6 hours when required for additional pain relief. Maximum of 8 tablets in 24 hours.
Supply 28 tablets.
Amitriptyline (neuropathic pain): starting dose
Age from 18 years onwards
Amitriptyline: titrate up from 10mg daily until pain settles
Amitriptyline 10mg tablets
Take one tablet at night. If pain does not settle, gradually increase the dose by one tablet (10mg) at night depending on response and if tolerated. Do not take more 75mg daily unless instructed by your doctor.
Supply 28 tablets.
Pregabalin (neuropathic pain): starting dose
Age from 18 years onwards
Pregabalin: titrate up from 150mg daily until pain settles.
Pregabalin 75mg capsules
Take one capsule twice daily. If pain does not settle, increase the dose to two capsules (150mg) twice daily after 3 to 7 days, then if needed, to a maximum dose of four capsules (300mg) twice daily after an additional 7 days, depending on response and if tolerated.
Supply 56 Capsules.
Gabapentin (neuropathic pain): starting doses
Age from 18 years onwards
Gabapentin: fast titration from 300mg to 900mg a day over 3 days
Gabapentin 300mg capsules
Take one capsule on the first day, then take one capsule twice a day on the second day, then take one capsule three times a day on the third day. If tolerated, increase the total daily dose by one capsule (300mg) every 2 to 3 days until the pain settles. Once you have reached 6 capsules (1800mg) daily, see your doctor to review this medicine before increasing the dose further.
Supply 100 capsules.
Gabapentin: fast titration from 900mg on day 1 onwards
Gabapentin 300mg capsules
Take one capsule three times a day for 3 days, then increasing the total daily dose by one capsule (300mg) every two or three days depending on response and if tolerated. Once you have reached 6 capsules (1800mg) daily, see your doctor to review this medicine before increasing the dose further.
Supply 100 capsules.
Gabapentin: slower titration regimen
Gabapentin 100mg capsules
Take one capsule at night, increasing by one capsule daily depending on response and if tolerated. Once you have reached 12 capsules (1200mg) daily, see your doctor before increasing the dose further.
Supply 100 capsules.
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