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American Academy of Neurology Practice Parameter: New Drugs, and Some Old Ones, Effective for Postherpetic Neuralgia

Class-I evidence supports the short-term efficacy of several treatments, including the long-controversial opioids.

This article conveys the American Academy of Neurology's educational, evidence-based recommendations on treatment of postherpetic neuralgia (PHN). After a careful and systematic review of the literature on the treatment of PHN, the authors rated 206 articles that met their search criteria according to classes of evidence, ranging from class I (prospective, randomized, blinded, controlled clinical trials in representative samples) to class IV (e.g., case reports).

Gabapentin, opioids, pregabalin, topical lidocaine, and tricyclic antidepressants have class-I evidence for efficacy in the treatment of PHN. Currently, however, insufficient data exist on the long-term benefits of these treatments. Topical aspirin and capsaicin have been found effective, but less so than the aforementioned treatments. Some evidence supports the efficacy of intrathecal methylprednisolone. However, due to a potential risk for arachnoiditis, transverse myelitis, and chemical meningitis, intrathecal methylprednisolone is recommended only in countries where the agent is available as a preservative-free preparation. A multitude of other treatments and interventions are reportedly not beneficial.

Comment: Aggressive treatment with analgesics and antiviral agents within 72 hours of the onset of herpes zoster is essential and might prevent some cases of postherpetic neuralgia. For a long time, tricyclic antidepressants were the mainstay of treatment for PHN. New agents have emerged in the past decade, in particular gabapentin and topical lidocaine. Opioids, the oldest drugs in the history of medicine, have only recently gained recognition for their efficacy in neuropathic pain. Such use in PHN has long been considered controversial. These new recommendations should clear up years of rhetoric and biases on this topic.

— Marco Pappagallo, MD

Dr. Pappagallo is Director, Division of Chronic Pain, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, Manhattan Campus for the Albert Einstein College of Medicine, New York City.

Published in Journal Watch Neurology November 29, 2004

Citation(s):

Dubinsky RM et al. Practice parameter: Treatment of postherpetic neuralgia: An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004 Sep 28; 63:959-65.

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