|
Category |
Class |
Type |
Examples |
Comment |
Multipurpose analgesics |
Antidepressants |
SNRIs Secondary amine TCAs Tertiary amine TCAs SSRIs |
Duloxetine, milnacipran, venlafaxine, desvenlafaxine Desipramine, nortriptyline Amitriptyline, imipramine Paroxetine, citalopram |
Established analgesics; duloxetine often selected first for chronic pain Established analgesics; better tolerated than the tertiary amine TCAs Established analgesics Poor evidence of analgesia |
|
Alpha-2 adrenergic agonists |
|
Tizanidine, clonidine, dexmedetomidine |
Tizanidine is oral and better tolerated than clonidine Clonidine used in spinal infusions; dexmedetomidine is used in critical care |
|
Cannabinoids |
Pharmaceutical Nonpharmaceutical |
Nabiximols, nabilone, dronabinol Medical cannabis |
Nabiximols not available in the United States; limited evidence for others Available in many states |
|
Glucocorticoids |
|
Dexamethasone, prednisone |
Commonly used in advanced cancer for pain/other symptoms |
|
NMDA receptor antagonists |
|
Ketamine, memantine, amantadine, dextromethorphan |
Evidence mixed but commonly used in palliative care for severe opioid-refractory pain. Efficacy in depression may increase use |
|
Neuroleptics |
First/second generation |
Haloperidol, olanzapine |
Poor evidence of efficacy |
|
Topical agents |
Local anesthetics NSAIDs Capsaicin Compounds |
Lidocaine 5% patch or cream, and lower concentration creams, gels, and patches Diclofenac ketoprofen .075% patch or cream, 8% patch Ketamine, amitriptyline, menthol, others |
5% patch used for neuropathic and musculoskeletal pain Approved for acute musculoskeletal pains .075% used for neuropathic or musculoskeletal pain; 8% patch may relieve PHN for months after short exposure in a monitored setting Limited evidence, costly; safety supports trials if available |
|
Botulinum toxin |
Botulinum A, B |
|
Evidence for use in many focal and regional neuropathic and musculoskeletal pain |
Drugs used for neuropathic pain |
Multipurpose adjuvant analgesics |
Antidepressants, α-2 adrenergic agonists, cannabinoids and other systemic drugs, topical drugs, botulinum toxins |
See above |
Most guidelines emphasize the antidepressants, the gabapentinoids, and the topical drugs for neuropathic pain; glucocorticoids are commonly used for neuropathic pain in advanced cancer |
|
Gabapentinoids |
|
Pregabalin, gabapentin |
Evidence in acute pain and chronic neuropathic pain; used first for neuropathic pain, unless comorbid depression supports antidepressant |
|
Other anticonvulsants |
|
Oxcarbazepine, lacosamide, topiramate |
Older drugs may be analgesic, but side effects support use of newer drugs; limited evidence overall |
|
GABA agonists |
GABAA GABAB |
Clonazepam Baclofen |
Poor evidence of analgesia |
|
Sodium channel blockers |
|
IV lidocaine, mexiletine |
IV lidocaine used for pain in monitored settings; oral drugs not used for pain due to limited evidence and side effects |
Drugs used for musculoskeletal pains |
Multipurpose adjuvant analgesics |
Antidepressants, alpha-2 adrenergic agonists, cannabinoids, topical drugs, botulinum toxins |
See above |
|
|
So-called muscle relaxants |
|
Methocarbamol, carisoprodol, chlorzoxazone, metaxalone, cyclobenzaprine |
No evidence in chronic pain; not used for chronic pain due to side-effect liability |
Drugs used for cancer-related bone pain |
Osteoclast inhibitors |
Bisphosphonates RANKL inhibitor Calcitonin |
Zoledronate, alendronate, ibandronate, Denosumab |
Used to prevent and treat pain and other SREs Poor evidence of efficacy |
|
Radioisotopes |
|
Samarium-153, strontium-89, phosphorus-32, others |
|
Drugs used for pain and other symptoms in cancer-related bowel obstruction |
Multipurpose adjuvant analgesics |
Glucocorticoid |
Dexamethasone |
Most patients receive a glucocorticoid and an opioid |
|
Antiemetics |
Dopamine antagonist, 5-HT3 antagonist |
Metoclopramide, haloperidol, ondansetron, granisetron |
|
|
Antisecretory drugs |
PPI, H2 blockers Anticholinergic drug Somatostatin analog |
Omeprazole, ranitidine Scopolamine, glycopyrrolate Octreotide, lanreotide |
Risk of cognitive side effects probably lessened by using drug with poor BBB penetration (ie, scopolamine, butylbromide, or glycopyrrolate) Evidence of efficacy is mixed and may not be a first-line approach for this reason |