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opioids), with sites of action in the periphery, spinal cord, and brain. At
least one RCT suggests that cannabinoids have a greater analgesic effect
than placebo. 35 However, in addition to a paucity of evidence, limitations
to this class include CNS depression and the concern over potential
abuse.
Proinflammatory interleukins (e.g. tumor necrosis factor-alpha) have a
role in inflammatory NP. It is premature to recommend agents intended to
counter these effects, but there is preliminary animal data to support a
possible future NP role for drugs like thalidomide (which inhibits tumor
necrosis factor-alpha production). 36–38
n Summary and recommendations
Neuropathy – overview 297
See other chapters for diagnosis-specific recommendations for various NP
etiologies.
First line: mild opioid (e.g. hydrocodone 5–10 mg PO q4–6 h) plus SNRI (e.g.
venlafaxine 75 mg PO QD)
Reasonable: opioid plus pregabalin (starting dose 50 mg PO TID)
Pregnancy:
n acetaminophen (650–1000 mg PO QID) and opioid (e.g. hydrocodone
5–10 mg PO q4–6h)
n there is insufficient data to recommend most of the anticonvulsants
or antidepressants for NP use in pregnancy; acute care clinicians should
consult with appropriate specialists before prescribing these agents
for NP
Pediatric: mild analgesic (NSAID or acetaminophen) with addition of
pregabalin (50 mg PO TID) if necessary (for patients aged at least
12 years)
Special case:
n if pain interferes with sleep: antidepressants (e.g. nortriptyline 50 mg PO
HS) are recommended as adjuvant therapy