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

[QUOTE=Synnove;1013129]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)


Hi Synnove

How are you doing with the Amitriptyline & Lyrica? Its been and still is a long battle for me too. I take 300 mgs Lyrica for Small fiber Neuropathy. It took 9 months to get here and the Lyrica is not helping as much as it could. My Neuro doesn't want to increase my dose. I recently started Amitriptyline 10 mgs a night. I also started very slowly. I took 5 mg (split pill) for a couple of mos. It helps me sleep, but I do not see a difference in my pain yet. I'm hoping I do not have to go much higher. I see you got up to 50 mgs. Dont think Ill make it that high. How "slowly" was your increase? Are you still feeling better with this medicine combo? Do you have any side effects with the lyrica? I had a lot of dizziness and my stomach was bloated for the first few mos but thats better now, so far no weight gain. But now my hair is falling out, not patches, but a lot of shedding.:eek: Needless to say Im very upset about this. The Dermatologist said to wait 2-3 months to see whats happens before I have to stop taking Lyrica. Did you have this problem with your hair? Sorry for the ramble and all the questions. just confused and depressed. Thanks..

Should I try again?
 

I was previously on Neurontin and felt that it helped for a while and over time the effects slowly went away so my dose was increased and increased until I got to 900mg 3 times a day. It got to the point where it wasn't working anymore. Then I was on nortyptiline for migraines, but it didn't help. Do you think it is worth it for me to try the 2 in combo?? Or is it a waste of time and money?

CiCi

Greetings, CiCi. Here's a link to the summary of a study recommending the combination: http://www.ncbi.nlm.nih.gov/pubmed/19796802
The difference between the combo and each drug separately isn't huge, but the researchers regard it as substantial. (And it's worked well for me.) But I haven't been able to find anything about the staging of the two--for instance, does it make a difference which one you start on? And if you're on a high dose of gabapentin (aka neurontin), and you add nortriptyline, can you then cut back on the gabapentin? I hope you can get good advice from a doctor you trust--though that's a struggle in itself for most of us.

Both drugs are available as generics, and on my insurance plan, they're pretty cheap. But I'm lucky to have a good insurance plan through my employer.

Lynn

Do you? Not trying to be a smart*** here; only you know what you're experience has been and what your pain is now.

As with any medication decision, it's about benefit vs. risk. Personally, I think it would at least be worth looking into, and then if you think it worth pursuing, take a copy of the study (and any other documentation/evidence) to your doctor and discuss it.

Doc

FWIW, I took amitriptyline (30 mg/day) and gabapentin (2000 mg/day) for many years. The amitriptyline had a sexual side effect that I didn't care for, so earlier this year I changed it to tramadol (200 mg/day) and am much happier with that. My level of pain relief is about the same, and I am not aware of any side effects from either, except possibly a mild cognitive and memory impairment. Or maybe that's just the real me, who knows.
Ron

hi Marie33
How are you doing with your meds?
Sorry I was away fro this site a few days.
Regarding what you were asking me regarding the combination of Lyrica and Amitriptyline. My neuropathy neuro dr. says he would recoment higher dose of Amitriptyline. But, I tell you, since my last post regarding this( must be a long time ago!) things has changed. I first started with Amitriptyline 10 mg for 2 weeks, then increase to 20 mg. And I am on Lyrica 100 mg in am, 100 mg at 2 pm and 150 mg at bed time. So then they started to increase it to 25 and then up to 50 mg. That was intolerable!! All my glands of any kind of liquid in my body closed up dry mouth, nose, eyes and every thing. So I went down to 30 mg, which I have been on for a while, but dr, sais to try to slowly increase it to 40. I tryed, but my throat closes up with hard mucus plugs at night, it is dangerous. I am down to 30 mg
You asked regarding how slowly I increased the dose, the neuro said verre slowly every 3 weeks or so
Regarding hair loss. Yes I do have a fair amount of hair loss, but I do not know if it is fram Lyrica, could be another symptom of some king of autoimmune condition.
I hope you have gotten answers to your dosing problems by now. I hope the medicine is working for you

BMS is KILLING me...new here
 

I am new to this site so I am sure I must not be looking in the right place but I am DESPERATE for help with BMS. I have suffered for years with BMS and dry eyes (restatsis for years) and only recently have been prescribed gabapentin but I have had NO RELIEF. Tonight is so bad I considered using burn gel in my mouth...the external only warning stopped me but when the pain is this bad I am willing to try anything! The most recent PCP has also prescribed procardia for my hands and feet which is helping but the headache from that medicine is killer.
Is there anyone out there in Pittsburgh, PA who is receiving help from a pcp or dentist?
Thank you and I really appreciate any and all suggestions!

Welcome to NeuroTalk:

Burning mouth can occur with low B12.

Also lipoic acid supplements help some people.

But commonly, toothpaste can be a culprit or mouthwashes.
Check your labels and buy a brand without Triclosan.

These are the 3 most common interventions. Otherwise, it might be a food intolerance or allergy.

I myself cannot tolerate citrus or tomatoes.

This is the very thing I discovered when I was looking around for an answer to my atypical trigeminal neuralgia pain.

However, my stomach is a war zone since I have GERD and went on many meds after developing this very horrible pain after some dental work (didn't have any pain going in).

I DID notice those that were getting improvement were taking some sort of combo of a tricyclic and Gabapentin.

Well...guess what? I take Desipramine (tablet) and a compounded cream and in that cream is Gabapentin.

I also keep my B12 and D levels optimized.

Improvement!

From Pgh with Dental Nerve pain in gums
 

I am being treated by a GP, his name is Geno Pavlick with Premier Medical. He is a very caring and intelligent doctor who listens and take over medication when you are getting no where with other doctors. Unfortunately I have no dentist referrals as most know very little about nerve damage. Currently I have taken gabapentin for 2 months with little improvement 600 mg twice a day is where I am, however, much research has indicated tricyclics antidepressants for mouth pain and I just started this week on Nortriptlyine. I will let you know how it goes. I do not have burning mouth, however, I have suffered with ulcers and burning at times and know it is painful. I found milk helped the burning and there are lidocaine mouthwashes they can prescribe. I also take a complex b vitamin and alpha lipoid acid supplement that they coaim helps heal nerves. I understand the desperation as I go thru it daily. I have had two teeth pulled and several root canals. I currently have a tooth hurting that was root canalled. Please update me on your progress. Maybe we can be some sort of support to one another.

Weary, don't forget to take vitamin D. In fact, you might want to ask to get your levels checked. I take D3, B complex and extra B 12 (methyl type)....as well as some other supplements.

My stomach could not take anymore meds.

Check out my previous posts to see what is in my compounded cream. And I also take Trycyclic medication (tablet).

Possible help/but CAUTION

Before I got the RX cream, I found a cream on line called ortho nesic gel that provided a tiny bit of help for short periods of time. BUT these types of creams placed on the face in particular are potentially dangerous, because they can burn or you can get some in your eyes. If you use this or anything like this, use a tiny amount and extreme caution. I also liked a heating pad (not when using any cream!) I also sometimes experimented with a lidocaine cream called LMX. Again, extreme caution is necessary.

Anyway, things aren't perfect for me, but my new routine is better and more manageable and I am grateful. Took a long time to get here. I pray it continues.

Good luck...if you haven't done so already, find yourself a great neuro and get your vitamin levels checked (might need to have a separate doc for this).