Nortriptyline + Gabapentin found most effective
 

The recent discussion of pros and cons of Gabapentin leads me to ask if people on this board have already discussed this widely cited study that concluded that the combination of Nortriptyline and Gabapentin reduces pain more effectively than either drug alone. Here's a link to the first page of the article. (It's from a journal called Evidence Based Medicine, a division of the British Medical Journal group.)

http://ebm.bmj.com/content/15/2/45.extract

I started on Nortriptyline; my neurologist just added an entry level dose of Gabapentin. So far it's helping. But my PN was diagnosed only about six months ago, so I'm not a very good test case.

Works wonderfully for me!
 

Hello! I was put on gabapentin and nortiptyline on August 24th (or 27th :rolleyes: ) and it has been sheer bliss for me! By the morning of the 4th day, all my pain was gone. :D:yahoo:

It has been a long battle for me getting the most effective medication for my neuropathy, (SFN, and long fiber, sensory motor and autnomic neuropathy) and the battle is not won yet.
I started out with Gabapentin a year ago, and had to increase the dose constantly until I was on such a high dose. I had side effects with dizziness and sometimes difficulties with certain coordinations and orientation.
I was switched to Lyrica. The same here, I needed high doses. I was up to 500 mg daily. This med has some similar effects, but not as severe. I can tolerate it better. But now, my neurologist suggested a combination of Amitriptyline and Lyrica. I think he feels this is the best med for the neuropathy.
I started slowly to introduse Amitriptyline in a low dose. And then, after this was getting tolerated in the body, they (neuro and rheumy) slowly verry slowly started to reduse the Lyrica. Then we increased the Amitriptyline at regular intervals.
But then, with Amitriptyline up to 50 mg daily, I got severe side effects with dry eyes and mouth. so we decrease again with Amitriptyline and increased Lyrica a little

The neurologist said that the Amitriptyline should be increased very slowly, so I will try. He said with very slow increase the body will tolerate it. I hope I will be able to tolerate the Amitriptyline and some Lyrica ( but low dose)

That's wonderful to hear! I too was reveling in the improvement--I added 200 mg daily of gabapentin to my 50 mg nortriptyline on August 16 and have had three weeks of low pain. Pain returned last night, so today I'm doing 3 rather than 2 100-mg tabs of gabapentin, and so far that's working pretty well. Who knows what the future will bring, but I'm with you. Let's "saturate ourselves" in whatever miracles we're granted.

Sorry, Synnove, I intended "that's wonderful to hear" as a response to Bluebelle. Thanks so much for sharing your longer and tougher journey. I don't have a firm diagnosis yet, but the neurologist says it's not JUST small-fiber, and I've detected some signs of what may be autonomic--so I may be facing the same triple threat you are. (And it's all still "idiopathic.")

As for the side effects of amitriptyline (which is supposed to be a form of nortriptyline), I started on 10 mg nortriptyline and increased by 10 mg a week, and that did seem to minimize dizziness and even dry mouth.

I hope I don't have to increase gabapentin too much. I don't like the prospect of a medication that induces some of the same problems -- such as coordination problems -- as the disease I'm taking it for....

Good luck with your current meds strategy, which makes sense to me.

ChaucerFan,yes, Amitriptyline and Nortriptyline is the same med. And, basically, gabapentil and Lyrica is in the same class, only Lyrica is the newest. Amitriptyline has been around for a long time.

So, are on 50 mg og the Nortriptyline, and you are tolerating that well? That sounds great, and with only 200 mg of Gabapentin in addition.

You see, I too, started with 10 mg of Amitriptyline daily for about 2 weeks, then I increased to 20 mg. Then my rheumy ordered 25 mg daily, and to increase to 50 mg in 1 week. I tell you, after 2 days I could hardly blink my eyes, the eyelids would not move, for dryness. and my mouth was like sandpaper, and I could hardly talk.
So we went right back to 30 mg daily, with 350 mg Lyrica. The dryness have gon( I am using artificial tears and Restasis and all kinds of mouth moisterationer.)
Neuropathy is still relentness!!
I hope that I can gradually increase the Amitriptyline, I think that is a good med for this. My neuro said he had pations ob that with 150 mg. He said, the tapering has to be gradual and slowly.
Hopefully, we all do not need any of this stuff anymore!!

Funny--my neurologist wanted me to go from 25 to 50, and I thought that would be too big a jump. (Of course the stuff is manufactured in 10, 25, and 50 mg. pills.) But I persuaded him to give me a script for one 25 and one 10 per night, and that's probably why I didn't have a problem tolerating the increase. By the way, another neurologist said she has people go to 75, but mine didn't think I'd get any more benefit at 75 than at 50. It's all trial and error. Anyway, best wishes for a low-pain day tomorrow!

Amitriptyline and nortriptyline are in the same class—both are tricyclic antidepressants—but they are not the same medication. Amitriptyline is a first-generation tricyclic, while nortriptyline is second-generation, and as such, generally has a lower incidence of side effects than amitriptyline, just as pregabalin generally has a lower incidence of side effects than gabapentin.

Doc

Dr. Smith, thank you for information on those meds. I did not realize, I thought they were just different trade names. Now, that you told me that, I will be asking the doctor to change to Nortriptyline. ( is it generic yes?-- I hope) With less side effects, that would be worth a try.

And I apologize for not having this right in my previous post.

Yes, nortriptyline is available generically.

No biggie—everyone makes mistakes. That's why they put Backspace and Delete keys on keyboards, and EDIT buttons on postings, right? ;)

Tip: The convention (and again it's no biggie) is that trade names are capitalized and generic names are not (unless beginning a sentence), e.g. Neurontin/gabapentin, Lyrica/pregabalin, Elavil/amitriptyline, Aventyl/nortriptyline. ;)

Doc