Which medications are indicated in the treatment of complex regional pain syndrome type 1 (CRPS 1) (RSD)?

Updated: Mar 09, 2021
  • Author: T P Sudha Rao, MD; Chief Editor: Herbert S Diamond, MD  more...
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Nonsteroidal anti-inflammatory drugs (NSAIDs) may provide some pain relief in patients with CRPS. However, they are not effective in altering the skin changes or natural history of the process and thus play only a supportive role.

A review of the use of anticonvulsants and antidepressants for treatment of CRPS-related pain found insufficient evidence to support the use of gabapentinoids, but noted that three randomized controlled trials (RCTs) did report significant improvement in pain with gabapentin, whereas one RCT found amitriptyline to be as effective as gabapentin. The efficacy of pregabalin has been described in pediatric patients with early CRPS, but only in case reports rather than RCTs. [21]

A course of high-dose corticosteroids (eg, prednisone 30-40 mg/d tapering over 2-4 weeks) can dramatically reduce pain, swelling, and stiffness. This enables the institution of an aggressive physical-therapy program. In general, corticosteroids are of most value in early CRPS (acute and subacute) when the bone scan shows increased uptake in the involved extremity.

Calcitonin is not an anti-inflammatory medication per se but has been reported to reverse the inflammatory changes and reduce pain in early CRPS, especially in patients with hyperdynamic blood flow. Subcutaneous injections of 100-160 units are administered daily for 4-8 weeks, then every other day for 3-6 weeks. A few reports suggest that intranasal calcitonin [22] may also be effective in treating RSD.

Oral and intravenous bisphosphonates (eg, alendronate) have demonstrated benefit in early CRPS. [23] In a randomized, double-blind, placebo-controlled trial, the aminobisphosphonate neridronate, administered intravenously, provided significant and persistent benefit in patients with CRPS. [24] Neridronate has received orphan drug designation by the US Food and Drug Administration for treatment of CRPS.

The anesthetic agent ketamine has shown promise in the treatment of CRPS. Intravenous administration of subanesthetic doses and topical application have been studied. However, the optimum dose and the route and timing of administration remain to be determined. [25, 26, 27]

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