Medications

These are agents that help counteract the condition's effect on the body. Many categories of medication have been used with varying degrees of success. These include analgesics (or pain-relievers) that affect the sympathetic nervous system, anti-epileptic medications, a variety of drugs called "psychotropics" that can alter mood and promote a feeling of well being, sleep aids, muscle relaxants and steroids. Make sure that your physician is thoroughly familiar with dose ranges, potential side effects, drug interactions and the drug's probability of success. In the early stages of CRPS, drugs alone are almost never a substitute for sympathetic blocks and limb reactivation but can be useful aids in treatment. (See injections and surgery.)

The selection of drugs depends upon several factors:

• Stage of the disorder
• Whether active sympathetic symptoms are associated with the pain
• Severity of associated muscle problems, such as spasms, muscle weakness and tremors
• Severity and type of any associated emotional problems, such as panic, anxiety, depression and sleep disturbances
• Whether there is suspected nerve or central nervous system lesion or injury
• How experienced, knowledgeable and current your physician is about CRPS

Many drugs can be obtained over-the-counter (OTC) and others are used in an "off-label" manner, meaning that the drug may be used to treat a condition for which it was not originally intended. An example of this is prescribing gabapentin (Neurontin), which was originally marketed as an epilepsy drug, for the neuropathic pain experienced by many CRPS patients. Gabapentin is widely used for neuropathic pain conditions because of its efficacy, safety and relative lack of side effects. Several studies conducted in a scientifically rigorous manner show that gabapentin is effective in several neuropathic conditions, such as post-herpetic neuralgia (nerve pain following an attack of shingles) and diabetic neuropathy (nerve pain from diabetes). The most common side effects – dizziness and sedation – usually can be avoided by starting gabapentin at low doses and increasing the dose every few days. Much higher doses may be needed for full effectiveness. Newer anti-epileptic drugs such as pregabalin (Lyrica) also are showing promise for the treatment of pain.

Many other categories of drugs have been used with varying degrees of success for CRPS. Assessing their usefulness is tricky for a variety of reasons, including:

• Variability of doses and responses among patients
• Inadequate prescribing by poorly trained physicians
• Multiple drug prescribing, which makes assessing response to the drug and side-effects difficult
• A strong placebo effect

Because information about medications used to treat CRPS is constantly changing, the following list of medications is by no means comprehensive. For more detailed information about medications used for CRPS, refer to the Physicans' Desk Reference at www.pdr.net. This is the resource most physicians use. Never use this information to treat yourself. It is no substitute for the experience and knowledge of your physician.

CRPS Medications

NonSteroidal Anti-Inflammatory Drugs (NSAIDs):

• Aspirin (Ecotrin, ASA)
• Diclofenac (Voltaren)
• Diflunisal (Dolobid)
• Celecoxib (Celebrex - a cox-2 inhibitor)
• Etodolac (Lodine)
• Ibuprofin (Advil, Nuprin, Motrin, etc.)
• Indomethacin (Indocin)
• Ketorolac (Toradol (only use for up to five days))
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)

Opioid-Like Drugs (Narcotics):

• Butorphanol Tartrate (Stadol)
• Nalbuphine (Nubain)
• Pentazocine Lactate (Talwin) (a category of drugs called opioid agonist-antagonists. They probably should not ever be used.)
• Codeine Phosphate (Codeine)
• Fentanyl Citrate (Fentanyl)
• Hydromorphone (Dilaudid)
• Morphine Sulfate (MS Contin, Noxamol)
• Oxycodone (Oxyir, Roxicodone, Oxycontin, Percocet)
• Buprenorphine (Subutex, Suboxone)
• Propoxyphene Napsylate (Darvon – N)
• Methodone
• Hydrocodone (Vicodin)

Opioid-Containing Combination Drugs:

• Hydrocodone/Acetaminophen (Anexsia)
• Propoxyphene/APAP (Darvocet)
• Butalbital/ASA/Caffiene/Codiene (Fiorinal with Codeine)
• Butalbital/APAP/Caffiene/Codiene (Fioricet with Codeine)
• Hydrocodne/Acetaminophen (Lortab)
• Hydrocodone/APAP (Norco)
• Oxycodone/Aspirin (Percodan)
• Hydrocodone/Acetaminophen (Lorcet)
• Carisoprodol plus Codeine (Soma with Codeine)
• Oxycodone/Acetaminophen (Tylox)
• Hydrocodone/Acetaminophen (Vicodin)
• Hydrocodone/Ibuprofen (Vicoprofen)

Other Analgesics:

• Acetaminophen (Tylenol, Panadol, Tempra, etc.)
• Tramadol (Ultram)

Anesthetics/Sedatives:

• Fentanyl Citrate (Fentanyl)
• Ketamine (Ketalar)
• Diphenhydramine (Sufentanil, Sleepinal)

Local Anesthetics:

• Bupivacaine (Marcaine, Bupivac)
• Lidocaine (Xylocaine)
• Mepivacaine (Carbocain)

Anxiolytics/Hypnotics (used when anxiety disorders and/or sleep disturbance is present):

• Lorazepam (Ativan)
• Temazepam (Restoril)
• Alprazolam (Xanax)
• Midazolam Hydrochloride (Versed)
• Oxzaepam (Serax)
• Diphenhydramine Hydrochloride (Benadryl)
• Chlordiazepoxide (Librium)
• Clonazepam (Klonopin)
• Clorazepate Dispotassium (Tranxene)
• Flurazepam (Dalmane)
• Buspirone (Buspar)
• Zolpidem (Ambien)
• Zaleplon (Sonata)
• Eszopiclone (Lunesta)

Anti-Epileptics (Anti-Convulsants):

• Carbamazepine (Tegretol)
• Clonazepam (Klonopin)
• Topiramate (Topomax)
• Gabapentin (Neurontin)
• Phenytoin (Dilantin)
• Valproic Acid (Depakene/Depakote)
• Tiagabine (Gabitril)
• Pregabalin (Lyrica)
• Diazepam (Valium)
• Lamotrigine (Lamictal)
• Levetiracetam (Keppsa)
• Oxcarbazepine (Trileptal)

Pregabalin is related to gabapentin and is approved to treat neuropathic pain, specifically diabetic peripheral neuropathy and postherpetic neuralgia. It is currently under review by the FDA for the adjunctive treatment of partial seizures and may have potential for treating CRPS.

Anti-Depressants:

• Fluoxentine Hydrochloride (Prozac)
• Paroxetine (Paxil)
• Sertraline Hydrochloride (Zoloft)
• Amitriptyline (Elavil)
• Desipramine (Norpramin)
• Venlafaxine (Effexor)
• Doxepin (Sinequan)
• Bupropion Hydrochloride (Wellbutrin)
• Nefazodone (Serzone)
• Trazadone (Desyrel)

Muscle Relaxants

• Baclofen (Lioresal)
• Carisoprodol (Soma)
• Methocarbamol (Robaxin)
• Tizanidine (Zanaflex)
• Cyclobenzaprine (Flexeril)
• Dantrolene Sodium (Dantrium)
• Diazepam (Valium)
• Quinine Sulfate (Quinaam)

Trans-Dermal Patches and Ointments May Contain:

• Catapres (Clonidine)
• Ketamine (Ketalar)
• Capsaicin (Zostrix)
• Fentanyl Citrate (Fentanyl – local anesthetic)

Combinations of drugs used for transdermal or intra-spinal use often are made by a process called compounding. Just a few select pharmacists make such medications.