Suggested algorithm

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With the alternatives offered, if a single agent in a particular group fails to help, then another can be selected from the same group (Figure 17.1).

There are some circumstances where treatment with drugs not normally utilized for neuropathic pain treatment can indirectly reduce neuropathic pain. For example, the muscle relaxant baclofen can reduce the pain of

Peripheral neuropathic pain - area of pain relatively small Topical lidocaine patch or Topical doxepin or Topical capsaicin

If no relief

L-Carnitine or lamotrigine or duloxetine or oxcarbazepine

If no relief IV lidocaine or epidural clonidine

Central neuropathic pain or peripheral neuropathic pain felt over large area

L-Carnitine or lamotrigine or oxcarbazepine or clonazepam or baclofen or duloxetine ▼

If no relief IV lidocaine

If no relief

Epidural clonidine or Epidural Hyaluronidase (if postlaminectomy scar tissue)

Acute flare-up of neuropathic pain

Baclofen or ondansetron or oxcarbazepine or clonazepam

If no relief

IV lidocaine or IV/IM ondansetron or IV/IM fosphenytoin or

If no relief Epidural clonidine

Figure 17.1 Suggested algorithm.

trigeminal neuralgia, while glyceryl trinitrate patches can be useful in the patient with ischemic neuritis caused by peripheral vascular disease or painful diabetic neuropathy where tissue ischemia can exacerbate neuropathic pain. The vasodilatory effects of nitrates can be used to maximize tissue perfusion and therefore indirectly reduce neuropathic pain.

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