Antidepressants

Amitriptyline

Form

Tablet: 10mg, 25mg, 50mg.
Oral solution: 25mg in 5mL; 50mg in 5mL.

Dose (oral)

2–12yr: initially 200µgs/kg (max. 10mg) once daily at night, increased if necessary; max. 1mg/kg/dose twice daily under specialist supervision.
12–18yr: initially 10mg once daily at night, increased gradually 3-5 days to initial max 75mg/day. Higher doses 150mg/day in divided doses under specialist supervision

Sleep and appetite improvement seen before pain improvement.

Contraindications and warnings: concurrent use CYP2D6.

Side effects: dry mouth, constipation, drowsiness.

Licence: not licensed for neuropathic pain in children.

Anticonvulsants

Gabapentin

Form

Capsules: 100mg, 300mg, 400mg. Tablets: 600mg, 800mg. Liquid: 50mg in 5mL

Dose and routes

By mouth

Child >2years

• Day 1 10mg/kg as a single dose (maximum single dose 300mg),
• Day 2 10mg/kg twice daily (maximum single dose 300mg),
• Day 3 onwards 10mg/kg three times daily (maximum single dose 300mg),
• Increase further if necessary to maximum of 20mg/kg/dose (maximum single dose 600mg).

From 12 years: the maximum daily dose can be increased according to response to a maximum of 3,600mg/day.

Contraindications and warnings: avoid abrupt withdrawal. Caution in renal failure:

Capsules can be opened and contents added to small volumes of fluid or food, the contents of the capsules are very bitter.

Licence: not licensed for this indication in children.

Carbamazepine

Form

Tablet (immediate release): 100mg, 200mg, 400mg.
Tablet (modified release): 200mg, 400mg
Chewable Tablets: 100mg, 200mg.
Oral liquid: 100mg in 5mL.
Suppositories: 125mg, 250mg

Dose (oral)

1 month–12yr: initially 5mg/kg at night or 2.5mg/kg twice daily, increased as necessary by 2.5–5mg/kg every 3–7 days; usual maintenance dose
5 mg/kg 2–3 times daily; doses up to 20mg/kg daily have been used
12–18yr: initially 100–200mg 1–2 times daily, increased slowly to usual maintenance dose 200–400mg 2–3 times daily; in some cases doses up to 1.8g daily may be needed.

Dose (Rectal)

1 month–18yr: use approx. 25% more than the oral dose (max. 250mg) up to 4 times daily

Contraindications and warnings: A-V conduction abnormalities, history of bone marrow depression, intermittent porphyria, MAOIs within previous 2 weeks, sensitivity to tricyclics. Dose reduce in advanced liver disease. Numerous drug interactions.

Licence: licensed for use in children.

Other medication for Neuropathic Pain

Ketamine

Specialist use only.

Can be useful IV, SC or orally for resistant nerve pain.

Dose and routes

By mouth or sublingual:

Child 1 month – 12 years: Starting dose 150µg/kg, as required or regularly 6 – 8 hourly: increase in increments of 150µg/kg up to 400µg/kg as required. Doses equivalent to 3mg/kg have been reported in adults,
Over 12 years and adult: 10mg as required or regularly 6 – 8 hourly; increase in steps of 10mg up to 50mg as required. Doses up to 200mg 4 times daily reported in adults.

By continuous SC or IV infusion:

Child 1 month – adult: Starting dose 40 µg/kg/hour. Increase according to response; usual maximum 100µg/kg/hour. Doses up to 1.5mg/kg/hour in children and 2.5mg/kg/hour in adults have been reported.

Nitrous oxide (Entonox)

This can be very helpful particularly for movement pain; the side effects are minimal and it is easy to administer and short acting. Children under 5 yr do not usually have sufficient respiratory power or co-ordination to administer.

Lidocaine patches

Use

Localised neuropathic pain

Dose and routes

Topical:

Child 3 - 18 years: apply 1-2 plasters to affected area(s). Apply plaster once daily for 12 hours followed by 12 hour plaster free period (to help reduce risk of skin reactions)
Adult 18 years or above: up to 3 plasters to affected area(s). Apply plaster once daily for 12 hours followed by 12 hour plaster free period (to help reduce the risk of skin reactions).

Notes

Not licensed for use in children or adolescents under 18 years.

Cut plaster to size and shape of painful area. Do NOT use on broken or damaged skin or near the eyes.

Transcutaneous electrical nerve stimulation (TENS) machines may also be helpful for bigger children with this type of pain.

Nerve block or epidural

May be helpful and can give lasting pain relief; consult local anaesthetic team. Epidurals can be managed in the community if the professional support is available.