Standard therapies

If a person has mild symptoms that do not disrupt daily life, standard pain relievers such aspirin, ibuprofen or paracetamol may provide adequate relief. However, it still may be advisable to remove the drugs causing neurotoxicity to reduce the chances of progressive nerve damage.

Once symptoms begin to interfere with quality of life, stronger medications are indicated. These include tricyclic antidepressants such as amitriptyline (Elavil), nortriptyline (Allegron, Pamelor), doxepin (Sinequan), and desipramine (Norpramin), which work by altering levels of neurotransmitters in the brain. These drugs often take a couple of weeks to show any effects and may cause side-effects including drowsiness, dry mouth, difficulty urinating, constipation, weight gain, and reduced libido. Another type of antidepressant, duloxetine (Cymbalta), is approved to treat diabetic neuropathy.

Anti-convulsant drugs indicated for treatment of epilepsy, such as phenytoin (Epinutin), carbamazepine (Tegretol),  and oxcarbazepine (Trileptal) may also be useful. One newer drug in this class, lamotrigine (Lamictal), has shown promising results for peripheral neuropathy pain in people with HIV and is less likely than other drugs in its class to interact with antiretrovirals.¹ Anti-convulsants may cause side effects including skin rash (and rarely the more severe Stevens-Johnson syndrome), drowsiness, dizziness, vision changes, and lack of coordination.

Gabapentin (Neurontin), approved for nerve pain related to herpes, has been studied in several trials for diabetic peripheral neuropathy with promising results. In one small placebo-controlled trial, gabapentin modestly reduced pain and improved sleep in patients with HIV-associated neuropathy.² In another study, the combination of gabapentin and B-complex vitamins significantly reduced pain and improved quality of life.³ Gabapentin is unlikely to interact with antiretroviral drugs.

If these drugs do not reduce pain sufficiently, more potent opiate pain-killers such as fentanyl (Actiq /Durogesic), methadone or oxycodone may be appropriate. Unfortunately, these drugs too are associated with side-effects, including drowsiness, itching and constipation and may cause dependence.