Tricyclics and opioids effective for the treatment of postherpetic neuralgia
The Journal of Family Practice. 2003 July;52(7):512-525
July 1, 2003|The Journal of Family Practice
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- BACKGROUND: Postherpetic neuralgia is defined as pain persisting at least 3 months following an acute episode of herpes zoster. TCAs and opioids have been shown to be effective for the treatment of this condition but they previously have not been compared with each other.
- POPULATION STUDIED: The researchers enrolled 76 patients, with an average age of 71 years (range, 32–90 years), recruited from physician referrals and from advertisements. Treatment allocation was concealed from the enrolling researcher.
- STUDY DESIGN AND VALIDITY: This was a randomized, double-blind, crossover study with 3 arms comparing morphine, nortriptyline, and placebo in the same patient. There were three 8-week segments—a 4-week titration phase, a 2-week maintenance phase, and a 2-week tapering phase—followed by a 1-week washout period.
- OUTCOMES MEASURED: The main outcome measure was pain relief, as measured on a 0 to 10 scale. A change in score of 1.4 was considered to be clinically relevant. Cognitive function was measured by the Wechsler Adult Intelligence Scale and the Hopkins Verbal Ability Test.
- RESULTS: Treatment with morphine decreased pain scores an average of 1.9 out of a possible 10. Treatment with TCAs decreased pain scores by 1.4. Both treatments were significantly better than treatment with placebo (P<.001 for morphine and P<.01 for TCAs).
PRACTICE RECOMMENDATIONS
Both tricyclic antidepressants (TCAs) and opioids are more effective than placebo for the treatment of postherpetic neuralgia.
Although there was a trend toward greater pain relief with opioids, their use was associated with a higher dropout rate. Since response to one medicine did not reliably predict response to the other, either may be tried for the treatment of postherpetic neuralgia.
