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topiramate had statistically significant decreases in pain (peak effects
occurred at 800 mg daily). 23
The N-methyl-D-aspartate (NMDA) antagonist memantine attenuates
phantom pain memory formation, but its utility seems to be limited to
early post-amputation prevention rather than in acute (ED) therapy. Trials
find little or no efficacy when the drug is used to treat acute PLP flares. 24–26
n Summary and recommendations
First line: salmon calcitonin (one or two IV doses of 200 IU, administered as a
20 min infusion) with as-needed opioids
Reasonable: gabapentin (300 mg PO HS on day one, followed by 300 mg PO
BID on day two, then 300 mg PO TID)
Pregnancy:
n the majority of the drugs discussed above are Pregnancy Category C or D;
weighing risks and benefits of PLP therapy during pregnancy may result in
a decision to delay institution of optimal therapy until after delivery
n opioid monotherapy may be used during pregnancy
n calcitonin (which may be used with appropriate consultation in pregnancy)
suppresses lactation and should not be used in breastfeeding patients
Pediatrics: salmon calcitonin (one or two IV doses of 200 IU, administered as
a 20 min infusion) with as-needed opioids
Special case:
n closely monitored setting: slow IV administration of midazolam (2–5 mg) or
ketamine (1 mg/kg)
n PLP refractory to other therapies: topiramate (starting dose 25 mg PO QD or
BID, with planned up-titration on follow-up)
References
Neuropathy – phantom limb pain 303
1. Baron R, Wasner G, Lindner V. Optimal treatment of phantom limb pain in the
elderly. Drugs Aging. 1998;12(5):361–376.