Opioids versus antidepressants in postherpetic neuralgia

Raja, Srinivasa N.; Haythornthwaite, Jennifer A.; Pappagallo, M.; Clark, Michael R.; Travison, Thomas G.; Sabeen, S.; Royall, Richard M.; Max, Mitchell B.

doi:10.1212/wnl.59.7.1015

Cited by 537 publications

(351 citation statements)

References 42 publications

(35 reference statements)

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“…Desipramine is a reasonable alternative to nortriptyline. In a crossover study of PHN comparing opioid analgesics, TCAs, and placebo, controlled-release morphine and TCAs provided significant benefits on pain (29). In this trial, patients preferred treatment with opioid analgesics compared to TCAs and placebo but there was a greater incidence of adverse effects and drop-outs during opioid treatment.…”

Section: Postherpetic Neuralgiamentioning

confidence: 97%

Herpes Zoster and Postherpetic Neuralgia in Older Adults

Schmader

2007

Clinics in Geriatric Medicine

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SynopsisHerpes zoster afflicts millions of older adults annually worldwide and causes significant suffering due to acute and chronic pain, or postherpetic neuralgia (PHN). Herpes zoster is caused by the reactivation of varicella-zoster virus (VZV) in sensory ganglia in the setting of age, disease and drug-related decline in cellular immunity to VZV. VZV-induced neuronal destruction and inflammation causes the principal problems of pain, interference with activities of daily living and reduced quality of life in older adults. To address these problems, the optimal treatment of herpes zoster requires early antiviral therapy and careful pain management. For patients who develop PHN, evidence-based pharmacotherapy using topical lidocaine patch, gabapentin, pregabalin, tricyclic antidepressants, and/or opiates can reduce pain burden. The live attenuated zoster vaccine is effective in reducing pain burden and preventing herpes zoster and PHN in older adults. KeywordsHerpes zoster; varicella-zoster virus; postherpetic neuralgia; elderly; aged IntroductionHerpes zoster is a neurocutaneous disease that is caused by the reactivation of varicellazoster virus (VZV) from a latent infection of dorsal sensory or cranial nerve ganglia following primary infection with VZV earlier in life. VZV is a double-stranded DNA herpesvirus with a genome that contains at least 70 gene products (1). VZV expresses gene products and attempts replication throughout life but cellular immunity is critical to containing VZV. With aging-related decline in cellular immunity to VZV, the virus may escape cell-mediated immune containment and spread in the affected ganglia and sensory nerves to the skin.Address correspondence to Dr. Schmader at 182 GRECC, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA, telephone: 919-286-6932, fax: 919-286-6823, kenneth.schmader@duke.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author Manuscript EpidemiologyThe estimated incidence of herpes zoster in persons older than 65 years old varies from approximately 10 to 14 cases per 1000 per year (2-4). The lifetime incidence of herpes zoster is estimated to be about 20-30% in the general population and maybe as high as 50% among those surviving to 85 years or higher (5). Current population figures and herpes zoster incidence data yield estimates of about 1 million new cases of herpes zoster each year in the United States (6). The incidence of recurrent herpes zoster is not as well established but the frequency of recurrent events is hig...

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Section: Postherpetic Neuralgiamentioning

confidence: 97%

Herpes Zoster and Postherpetic Neuralgia in Older Adults

Schmader

2007

Clinics in Geriatric Medicine

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“…105 Similar observations were made in a double-blind, placebo-controlled, crossover trial examining the effects of opioids (morphine or methadone) and tricyclic antidepressants (nortriptyline or desipramine) in patients with PHN. 107 Although the opioids were moderately superior to the TCA against pain, 20 of the initial 76 subjects dropped out during the opioid phase, whereas 6 subjects withdrew during the TCA phase. 107 In these studies, adverse effects included changes in mood, irritability, personality changes, and decreased cognitive functions.…”

Section: Current State Of the Art: Pharmacologic Treatmentsmentioning

confidence: 99%

“…107 Although the opioids were moderately superior to the TCA against pain, 20 of the initial 76 subjects dropped out during the opioid phase, whereas 6 subjects withdrew during the TCA phase. 107 In these studies, adverse effects included changes in mood, irritability, personality changes, and decreased cognitive functions. 105,107 It is telling that some individuals would abandon opioid therapy in spite of reduction in pain.…”

Section: Current State Of the Art: Pharmacologic Treatmentsmentioning

confidence: 99%

“…107 In these studies, adverse effects included changes in mood, irritability, personality changes, and decreased cognitive functions. 105,107 It is telling that some individuals would abandon opioid therapy in spite of reduction in pain. In this regard, it is emphasized that neuropathic pain is a chronic condition and appropriate treatments need to be considered in the context of long-term therapy.…”

Section: Current State Of the Art: Pharmacologic Treatmentsmentioning

confidence: 99%

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Challenges in the development of novel treatment strategies for neuropathic pain

Ossipov

Porreca

2005

Neurotherapeutics

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Summary:Neuropathic pain might best be considered as a collection of various pain states with a common feature, that being symptoms suggestive of dysfunction of peripheral nerves. The development of therapeutic options for the treatment of neuropathic pain is complicated significantly by several factors. Neuropathic pain may arise from widely diverse etiologies such as physical trauma, disease, infection, or chemotherapy. Symptoms indicative of neuropathic pain may also arise in individuals with no evidence of any type of nerve trauma (idiopathic). Although neuropathic pain is a substantial health care issue, it is relatively uncommon and only occurs in a small fraction (Ͻ10%) of individuals with these initiating factors. Moreover, the efficacy of treatment protocols, even against the same type of symptoms, differ depending on the underlying initiating cause of the neuropathy. Although these observations strongly suggest that there are predisposing factors that may impart susceptibility to the development of neuropathic pain, no common predisposing factors or genetic markers have been satisfactorily identified. Because of these vagaries, treatment of neuropathic pain has been based on trial and error. However, recent progress in the understanding of neurophysiologic changes that accompany peripheral nerve dysfunction indicate that regulation of ion channels that maintain membrane potentials or generate action potentials may provide an important therapeutic approach. Neuropathic pain is accompanied by increased activity of peripheral nociceptors, which is produced in part by changes in levels of specific calcium and sodium channels. The identification of sodium and/or calcium channels subtypes that are expressed almost exclusively on nocicpetors may provide a way of regulating the activity of exaggerated nociceptor function without altering other sensory modalities. Thus, the selective targeting of ion channels may represent a viable therapeutic target for the management of the neuropathic pain state, regardless of etiology.

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“…There is ample scientific evidence to support the use of tricyclic antidepressants (TCAs) in neuropathic pain [15,16]. Although the literature for use of TCAs in CRPS is lacking, the drugs are commonly used for CRPS management.…”

Section: Antidepressantsmentioning

confidence: 99%

Pharmacologic therapies for complex regional pain syndrome

Mackey

Feinberg²

2007

Curr Pain Headache Rep

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Complex regional pain syndrome (CRPS) remains a challenging condition to diagnose and treat. There are few large-scale, randomized trials of pharmacologic agents, and most published studies are small, uncontrolled, or presented only in abstract form at meetings. The most commonly used agents, such as anticonvulsants, anti-depressants, and opiates, have been found to be useful for other neuropathic pain conditions in large-scale trials but have not been adequately studied in CRPS. Systemic steroids delivered by multiple routes continue to be used, with some good evidence for short-term administration. N-methyl-D-aspartate antagonists have recently gained in popularity, without evidence from well-controlled trials. Bisphosphonates have been well studied and offer promise. In addition, there has been interest in thalidomide; however, we are still awaiting well-controlled trials. This article presents an overview of the available data regarding pharmacologic therapies for CRPS. These agents should be used in conjunction with a comprehensive interdisciplinary approach aimed at functional restoration and improved quality of life.

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Opioids versus antidepressants in postherpetic neuralgia

Abstract: Opioids effectively treat PHN without impairing cognition. Opioids and TCA act via independent mechanisms and with varied individual effect.

Cited by 537 publications

References 42 publications

Herpes Zoster and Postherpetic Neuralgia in Older Adults

Herpes Zoster and Postherpetic Neuralgia in Older Adults

Challenges in the development of novel treatment strategies for neuropathic pain

Pharmacologic therapies for complex regional pain syndrome

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