What treatments are available?

The treatment of nerve damage is really two-fold. The first part is dependent on what the tests show. If an underlying cause is revealed by the tests then that will be treated and the treatments depend on the cause. For example, if you have nerve damage in your feet and it is found that you have diabetes the most important thing to do is treat and control the blood sugars. While this may not reverse the symptoms that you have it will definitely help prevent them from getting any worse. If you have a more unusual condition such as Guillain Barre syndrome then the treatment is a form of immune therapy that will allow the nerves to become insulated again and therefore start working properly.

When pain is the predominant symptom there are several medications that can be used to provide pain control and this may be given alongside the treatments mentioned above- for example if you have diabetes causing a painful neuropathy then your treatment will involve the medications to control blood sugar plus the medications to control pain.

Medications and side-effects:

The main thing to note about these pain-killers is that they are taken every day or not at all. They are started at a low dose and at this dose they may not help the symptoms. The idea of the low dose is two-fold- firstly it increases the chance of tolerating the medication and secondly some people will actually get sufficient relief from a small dose. They need to be taken at a proper dose for a proper amount of time before you can decide they don’t work. By this I mean the dose needs to reach a level where you would expect relief from symptoms and the duration of treatment needs to be long enough to allow it to work and this is usually at least 4 weeks or longer. The main side-effects tend to be fatigue and excessive tiredness and some people experience dizziness or lightheadedness. If the side-effects are mild then if you persist with the medication the side-effects may fade away.

The medications are only used to treat pain, burning or tingling. They won’t help if the main symptom is numbness.

If you try the medication and tolerate it ok then even if the medication only takes the edge off the pain it may be worth increasing the dose as there is a chance the dose is just too low.

It is extremely useful to keep a note of all the medications you have tried, the doses you were on and if you stopped it the reason why.

There are several medications used to treat neuropathic pain and listed below are the ones I use and therefore have the most experience with:

• Treatments I use
• Lyrica (pregabalin)
• Neurontin (gabapentin)
• Amitriptyline
• Cymbalta (duloxetine)

Lyrica (pregabalin): This medication helps pain by dampening down the response of the nerve so it becomes less excitable and this in turn helps reduce the pain. It can cause dizziness or lightheadedness and some patients feel excessively fatigued on it. However, sometimes these side-effects fade away after being on the medication a few weeks. The starting dose is usually 25mg twice daily and then it increases over the coming weeks to 150mg twice daily. It can also be taken 100mg three times daily. Some people get enough of a response from 75mg twice daily.

Neurontin (gabapentin): This medication is similar to pregabalin but is not the exact same. Side effects of this medication include fatigue, dizziness, water retention and loss of balance. It is not known exactly how it works for nerve pain but it is thought to blunt the nerve responses and in this way reduce the pain signals. The dose here is usually 100mg three times daily and then titrated upwards towards 900mg three time daily. It can go as high as 3600mg in the day in divided doses.

Both lyrica and Neurontin take several weeks before reaching their full effect. During this time the dose can be slowly increased.

Amitriptyline: this medication is an old anti-depressant. Some people become hesitant about taking this medication because it is an old anti-depressant (in fact it is rarely even used to treat depression anymore and is primarily now used for pain). However, as an anti-depressant the dose is between 150 and 300mg daily. As a pain medication it starts at 10mg daily (taken at night) and increases in 5-10mg increments to a dose of no more than 100mg nightly (although usually not greater than 50mg nightly).  It helps pain by altering the perception of pain through changing levels of neurotransmitters in the brain. This particular medication can  take up to 6 weeks to reach its full effect. Its main limiting side effects can be dry eyes, dry mouth, constipation and blurred vision. These side effects tend to fade away after a few weeks of being on the medication. The other main side effect is fatigue or sedation- this is why it is taken at night. Sometimes this can actually be a helpful side-effect if sleeping with the pain is difficult.

Duloxetine: this medication is an antidepressant that also helps with pain. It starts at a dose of 30mg daily to be escalated to 60mg and as high as 120mg daily as necessary. Side-effects include dizziness, fatigue and nausea. This medication is best taken with food because of the nausea.

Sometimes it is a combination of the above medications that eventually makes a difference to the pain.

Capsaicin Cream- this is a topical medication which has been shown to improve pain through changing the levels of certain neurotransmitters that are associated with pain. It is typically applied 4 times daily. It is reserved for those patients who do not respond to the oral medications or cannot take them because of side effects.