| Drugs/Routes |
Usual starting dose (mg/day) |
Usual effective dose range (mg/day) |
Dosing schedule |
Comments |
| Anticonvulsants: |
| carbamazepine (Tegretol) PO |
200 |
600-1200 |
q6-8h |
|
| clonazepam (Klonopin) PO |
0.5 |
0.5-3.0 |
q8h |
|
| divalproex sodium (Depakote) PO |
500 |
1500-3000 |
q8h |
|
| phenytoin (Dilantin) PO |
300 |
300 |
hs |
Loading doses may be used, e.g., 500 mg x 2. |
| phenytoin (Dilantin) IV |
500-1000 |
? |
? |
IV dose used for rapidly escalating neuropathic pain. |
| valproate sodium (Depacon) IV |
max. 20 mg/kg over 5 min |
? |
? |
IV dose used for rapidly escalating neuropathic pain; followed by PO doses. |
| gabapentin (Neurontin) PO |
100-300 |
300-3600 |
q8h |
May increase dose daily. |
| Tricyclic Antidepressants: |
| amitriptyline (Elavil) PO |
10-25 |
50-150 |
hs |
Traditionally amitriptyline was first line. Due to side effects and recent evidence of comparable analgesia, desipramine is preferred for many patients, especially the elderly; less hypotension with nortriptyline. Evaluate and titrate upward q3-5 days. |
| clomipramine (Anafranil) PO |
10-25 |
50-150 |
hs |
| desipramine (Norpramin) PO |
10-25 |
50-150 |
hs |
| doxepin (Sinequan) PO |
10-25 |
50-150 |
hs |
| imipramine (Tofranil) PO |
10-25 |
50-150 |
hs |
| nortriptyline (Aventyl, Pamelor) PO |
10-25 |
50-150 |
hs |
| "Newer" Antidepressants: |
| fluoxetine (Prozac) PO |
10-20 |
20-40 |
qd |
"Newer" antidepressants have fewer side effects than tricyclics; less evidence of effectiveness. |
| paroxetine (Paxil) PO |
20 |
20-40 |
qd |
| sertraline (Zoloft) PO |
50 |
150-200 |
qd |
| Corticosteroids: |
| dexamethasone (Decadron) PO |
Low-dose regimen: 1-2 mg |
same
|
qd or bid
|
In advanced medical illness, long-term treatment with low doses is generally well tolerated; used when pain persists after optimal opioid dosing. |
| High-dose regimen: 100 mg then 96 mg in 4 divided doses |
same |
qid |
High doses used for acute episodes of severe pain unresponsive to opioids. |
| Local Anesthetics: |
| mexiletine (Mexitil) PO |
150 |
900-1200 |
q8h
|
Mexiletine is safer than tocainide. Plasma concentrations should be followed to reduce risk of toxicity. |
| lidocaine IV |
2-5 mg/kg |
___
|
___
|
Brief infusion over 20-30 minutes. Analgesia occurs within 15-30 minutes. May be appropriate for rapidly escalating neuropathic pain. |
| lidocaine subcutaneous, IV |
2.5 mg/kg/h |
same
|
___
|
Continuous infusion. |
| Others: |
| baclofen (Lioresal) PO |
15 |
30-200 |
q8h
|
Indicated for "shooting" neuropathic pain. |
| calcitonin subcutaneous, IV |
25 IU |
100-200 IU |
qd |
Calcitonin is indicated for various neuropathic pains; bone pain; and possibly osteoarthritis. |
| calcitonin nasal spray (Miacalcin) |
200 IU |
200-400 IU |
qd |
| clonidine transdermal (Catapres) |
0.1 |
? |
qd |
Clonidine doses may be increased by 0.1 mg/day q3-5 days. Multipurpose for chronic pain. |
| clonidine PO |
0.1 |
? |
qd |
