Commonly Used Medications
The goal is pain less than a 4/10, the patients’ ability to cope with day to day function and sleep.
The importance of maintaining range of motion and decreased swelling to help with pain is key. Patient and therapist cannot rely just on pain medication, as physical measures are key for treating pain, stiffness and contracture.
The following are common medications that can be used to help control neuropathic pain:
1. Nortriptyline or amitriptyline, starting at 10 mg at night and increasing up to 50 mg at night. The common side effects of this medication are dry eyes, dry mouth and a feeling of being “hung over” in the morning, if the dose is too high. This medication can be given as early as dinnertime if there is a hangover effect with some sedation still in the morning.
2. Gabapentin starting with 300 mg three times a day. This dose can be slowly titrated up to 600 - 900 mg three times or four times per day. Common side effects are feeling drowsy, weight gain and leg swelling.
3. Pregabalin (Lyrica) starting with 75 mg twice a day for one week and then 75 mg in the morning and 150 mg at night for one week and then 150 mg bid. The max dose is 300 mg twice a day.
If a combination of Nortriptyline and Gabapentin/Pregabalin are not working, second line agents include the following:
4. Duloxetine (Cymbalta) 30 mg daily for one week. - This often causes nausea that lasts for about a week, but this will settle. If pain is still insufficiently controlled, can increase to 60-90 mg daily.
For pain when the skin is touched or sensitivity to sheets or other touch-induced pain, please use the following:
5. Compounded cream in a Lipoderm or Lipoderm max base 100 mL tube in a pump, one to two pumps applied to the painful area up to four to five times a day. Prescribe 400 mL, but dispense in 100 mL tubes. Compounding solution to contain 10% ketamine, 10% gabapentin, 4% amitriptyline, 5% lidocaine and 10% Voltaren.
Do not drive a car or operate machinery while taking a narcotic medication. Gabapentin, Lyrica, nortriptyline and Cymbalta can be somewhat sedating, so do not drive when these medications are being changed or modified as you may notice sedation.
