1. Class
Medication
Recommendatio n
Starting dose
Max dose
Adequate Trial
Side Effects
Precautions
TCA
Nortriptyline
(or Amitriptyline)
First Line
25mg qhs
Increase 25mg/day every 5 days up to 150mg/day
4-6 weeks (>2 weeks at max tolerable dose)
Sedation, dry mouth, blurred vision, urinary retention
Cardiac disease, seizure disorder, use with tramadol
Ca++ channel α2-δ ligands
Gabapentin
mg qhs or TID
Increase by mg every 3-7 days, up to 3600mg/day
3-8 weeks for titration, (>2 weeks at max tolerable dose)
Sedation, dizziness, peripheral edema
Dose adjusted for renal impairment
Pregabalin
50mg TID or 75mg BID
Increase every 3-7 days up to 300mg/day*
4 weeks
SSNRI
Duloxetine
30mg once daily
Increase to 60mg/day after 1 week
Nausea, sedation
Hepatic or renal insufficiency, use with tramadol
Venlafaxine (>150mg/day)
37.5mg once daily or BID
Increase 75mg/week until relief, or 225mg/day
4-6 weeks
nausea
Topical Lidocaine
Lidoderm 5% patch, oint.
First Line for Localized pain
Apply 1-3 patches
3 patches/12 hours each
3 weeks
Local irritation, rash
None
Opioid Agonists
Oxycodone
Second Line**
5mg q 6hr or PRN
Can convert total daily dose to LA after 1-2 weeks, maintain short acting as breakthrough
Constipation, drowsiness, dizziness
History of substance abuse, long term use
Morphine
10-15mg q 4hr or PRN
Tramadol
50mg once or twice daily
Increase mg/day every 3-7 days up to 400mg/day
Constipation, drowsiness, dizziness, seizures
Use with serotonergic drugs (SSRI, SNRI), age >75 max dose is 300mg