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following article was published in the Fall/Winter 2001 edition of
COMMUNICATOR A Fact Sheet on GBS for the General
Practitioner/Primary Care Physician by Joel S. Steinberg, MD, PhD
These are followed by
Pain: Weakness is the major feature of GBS. However, many patients also
experience some degree of paresthesias (abnormal sensations), such as
numbness, tingling, formications (a sense of insects crawling under the
skin) and even pain. These may be felt in the feet, hands, and elsewhere.
They may become more prominent when the patient is fatigued. Of the
various paresthesias that the GBS patient may experience, pain is the most
problematic and thus usually merits treatment. Several options may be
tried. Treatment should be customized.
(I) Over the counter analgesics
usually offer a safe initial approach to pain relief. Choices include
acetaminophen (Tylenol); aspirin or ASA, including formulations to reduce
the risk of upset stomach (enteric coated aspirin [Ecotrin], aspirin with
antacid (Ascriptin); ibuprofen (Advil) and naproxen (Aleve). In addition,
other non-prescription approaches, such as moist heat or cold applications
may be considered.
Of prescription drugs, the following products are sometimes helpful to
relieve pain. The more popular medications, in part reflective of results
of formal studies are bolded.
(II) Prescription analgesics. Several drugs are available in this
group. These include propoxyphene (e.g. Darvocet N-100),
Ultracet), non-steroidal anti-inflammatory drugs (NSAID's),
Compound [with aspirin]) [watch for dependence], opioids, the local
analgesic lidocaine, applied as a 5% patch (Lidoderm) and topically
applied capsaicin (applied to the skin up to 4 times a day). Long acting
analgesics, such as fentanyl (Duragesic Patch), a narcotic analgesic, may
reduce the risk of addiction. As a generalization, opioids may not be that
helpful for neuropathic pain. Furthermore, a potential for addiction and
constipation may limit their practical use. The latter may be addressed
with sufficient dosing of senna concentrate (e.g. Senokot tablets) or
lactulose syrup, to obtain a comfortable daily bowel movement.
(III) Tricyclic antidepressants are attractive in part due to low
cost, as they are available generically. An example is
It can be started at a low dose, 10mg q. h.s., and doubled every few days
to weeks, as tolerated, until pain is reduced or side effects become too
annoying (dry mouth, etc.) A maximal dose is 150mg. Other tricyclic
amitriptyline (Elavil, Endep),
Pertofrane) and doxepin (Sinequan), a dibenzoxepin, may also be
considered. Nortriptyline and other tricyclics can be combined with the
anti-seizure medications described below.
(IV) Selective serotonin uptake inhibitors (SSUI). Among this class of
paroxetine (Paxil) has been used to suppress pain.
(V) Anticonvulsants. Several drugs originally developed and
marketed to treat seizures (anticonvulsant or antiseizure drugs) have
become popular to suppress pain. Historically
phenytoin (Dilantin) and
carbamazepine (Tegretol) had been found helpful to reduce pain. However,
untoward side effects have led to a preference for newer, safer
1. Gabapentin (Neurontin) (available as 100, 300, 400, 600 and
800mg capsules) is perhaps the most popular medication in the
anticonvulsant group. It can be started at a low dose, of 100mg a day, and
doubled, every 4-7 days, in a bid to tid regimen, to doses as high as
4,000mg total daily, until pain abates. If dizziness, somnolence or other
side effects develop, decease to the prior dose for 1-2 weeks, until side
effects abate. Other potential anticonvulsant options are listed below.
2. Topiramate (Topamax) (available as 25, 100 and 200mg tablets) is
typically started at 25-50mg and increased, every 1-2 weeks, as a bid
regimen, to total daily doses of 50 (as 25mg bid) to 400mg (200mg bid)
dosing. If drowsiness or weight loss develop, decrease the dose for 2 to 4
weeks until side effects abate.
Lamotrigine (Lamictal), another antiseizure medication (available
in 25, 100, 150 and 200mg tablets) should be started at a very low dose,
25mg every other day, to reduce the risk of severe skin rash. It can be
increased, every other week, to two times a day, and then doubled every
other week, up to 250mg twice a day. At least one study (Aakrzewska,
Pain73:223; 1997) supports its potential ability to relieve pain.
Zonisamide (Zonegran: 100mg capsule) is a newer anticonvulsant
agent. Initially started at 100mg daily, the dose is increased after a
steady state is achieved at two weeks (due to its long half life), at
100mg increments, to 200 and even 400mg daily. Potential side effects
include somnolence, anorexia, dizziness, headache, nausea and
agitation/irritability. Formal study evidence for pain reduction
capability iw wanting.
Oxcarbazepine (trileptal: 150, 300 and 600mg tablets) also a
newer anticonvulsant agent, is reported to have efficacy comparable to
Tegretol. It is usually started at 300mg bid and increased as may be
warranted, at weekly intervals, to 600mg bid and then to 1200mg bid.
Potential side effects include headache, somnolence or fatigue, dizziness,
viral infection, nausea and asymptomatic hyponatremia.
6. Valproic acid (Depakene: 250mg capsule, Depakote) is a
carboxylic acid type of anticonvulsant that has been used to suppress
pain. The recommended dosing for seizures is 15mg/kg/day (1,000mg for a
70kg [150 lb] patient, and can be increased every week by 5-10mg/kg/day
(about 250-500mg/70kg), to a servative dosing has been recommended,
starting at 500mg per day, and increased by 100mg per week. Various
studies suggest its value to relieve pain. A potential for liver toxicity
warrants monitoring of hepatic function during the first six months of
7. Clonazepam (Klonopin, 0.5, 1, 2mg tablets), in the
benzodiazepine group of anticonvulsants (along with chlordiazepoxide
[Librium], etc.), has helped suppress pain in a small percentage of
patients. Divided day doses, raised slowly up to 3mg total per day are
usually tolerated, and a daily dose as high as 8mg have been successfully
used. Potential side effects, drowsiness, fatigue and lethargy, tend to
subside with continued use.
(VI) Cardiac antidysmythmia agents. Some drugs, marketed for
cardiac dysmythmias (arrhythmias), have sometimes been used to treat pain.
An example is mexiletine (Mexitil).
Non-medication treatments. In addition to medications, several
other methods have been employed to relieve pain. These include
acupuncture, pool therapy, transcutaneous electric nerve stimulation and
nerve blocks. As is true for most aspects of medicine, treatment
approaches should be individualized for each patient.
Submitted to me by
Jethro 10 Jan 03
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This page was last modified:
January 06, 2006