Cappuzzo TCAs/selective serotonin-norepinephrine reuptake inhibitors pain mechanisms. Ultimately, though, each pain management (SNRIs) were considered essentially equivalent as drugs regimen needs to be tailored to the individual patient. of ﬁrst choice based on pooled NNT and number needed PGB appears to be an efﬁcacious, well-tolerated option for to harm (NNH) data from available RCTs.29 SNRIs show the treatment of PHN. PGB has some advantages over other promise as potential therapies for other types of neuropathic available, recommended therapies, but cost may be an issue pain, but clinical trial data to support their use for PHN are versus other established treatments. Additionally, long-term not yet available.29,30 PGB and gabapentin were treated as safety and efﬁcacy of PGB still need to be established. essentially “interchangeable” since the authors felt that the data were insufﬁcient to allow for separate analyses of PGB and gabapentin.19,29 If a patient has a contraindication to using a TCA, such as ischemic heart disease or cardiac conduction abnormalities, PGB/gabapentin would be preferred over a TCA.10,29 A subsequent cost-effectiveness analysis by Smith and Roberts30 largely agreed with the algorithm recommended by Finnerup et al29 suggesting that gabapentin/PGB and TCAs appeared to be reasonable ﬁrst choices for PHN from both a clinical and economic standpoint in patients without coronary artery disease, while gabapentin/PGB were clearly favored in patients with coronary artery disease or who had other contra- indications to using TCAs.30 Smith and Roberts also examined PGB and gabapentin data separately, and, they noted that, if treated separately, gabapentin appeared to be preferred over PGB due to higher side effect discontinuance rates in some trials.30 Another cost-effective analysis comparing desipramine, gabapentin, and PGB for the treatment of PHN in hypothetical older adults 60 to 80 years of age concluded that desipramine was more cost-effective than the other agents.31 However, the study only analyzed the use of these three agents in patients with no known ischemic heart disease or no cardiac conduction abnormalities. It is important to note that many PHN patients require trials of different therapies to achieve adequate pain relief; in fact, they often require more than 1 agent to manage their pain. There is no clinical trial or cost-effectiveness data available on PGB used in combination therapy for PHN. Conclusion PHN is a devastating consequence of HZ that signiﬁcantly affects patient quality of life. Despite positive ﬁndings with several drug classes, the very heterogeneous nature of PHN makes successful pain management difﬁcult. The response to therapy may vary within a single patient as well as from patient to patient. Often, trials of more than 1 agent are necessary before adequate pain management is achieved. Regardless of which agent is tried ﬁrst, due to the complexity of PHN symptoms, it is not surprising that a single agent may not provide adequate pain relief. Many patients require a combination of therapies each ideally targeting different 22 Disclosures The author has no conﬂicts of interest to declare. References 1. Bader MS, McKinsey DS. Viral infections in the elderly: the challenges of managing herpes zoster, influenza, and RSV. Postgrad Med. 2005;118:45–54. 2. Stacey BR, Glanzman RL. Use of gabapentin for postherpetic neuralgia: results of two randomized, placebo-controlled studies. Clin Ther. 2003;25:2597–2608. 3. Argoff CE, Katz N, Backonja M. Treatment of Postherpetic Neuralgia: A Review of Therapeutic Options. J Pain Symptom Manage. 2004;28:396–411. 4. Mounsey AL, Matthew LG, Slawson DC. Herpes zoster and posther- petic neuralgia: prevention and management. Am Fam Physician. 2005;72:1075–1080. 5. Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63:959–965. 6. Johnson RW. Pain following herpes zoster: implications for manage- ment. Herpes. 2004;11:63–65. 7. Sabatowski R, Galvez R, Cherry DA, et al. Pregabalin reduces pain and improves sleep and mood disturbances in patients with post-herpetic neuralgia: results of a randomised, placebo-controlled clinical trial. Pain. 2004;109:26–35. 8. Engberg IB, Gröndahl GB, Thibom K. Patients’ experiences of herpes zoster and postherpetic neuralgia. J Adv Nurs. 1995;21:427–433. 9. Moulin DE, Clark AJ, Gilron MD, et al. Pharmacological management of chronic neuropathic pain – Consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage. 2007;12:13–21. 10. Dworkin RH, Miroslav B, Rowbotham C, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol. 2003;60:1524–1534. 11. Attal N, Cruccu G, Haanpää M, et al. EFNS guidelines on pharmacologi- cal treatment of neuropathic pain. Eur J Neurol. 2006;13:1153–1169. 12. Gore M, Sadosky A, Tai Kei-Sing, et al. A retrospective evaluation of the use of gabapentin and pregabalin in patients with postherpetic neuralgia in usual-care settings. Clin Ther. 2007;29:1655–1670. 13. Finnerup NB, Otto M, Jensen TS, et al. An evidence-based algorithm for the treatment of neuropathic pain. MedGenMed. 2007;9:36. 14. Dworkin RH, Corbin AE, Young JP, et al. Pregabalin for the treatment of postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology. 2003;60:1274–1283. 15. Bockbrader HN, Burger P, Corrigan BW. Population pharmacokinetics of pregabalin in healthy volunteers, renally impaired patients, and patients with chronic pain. Presented at the meeting of the American Pain Society; March 14–17, 2002;Baltimore, MD. 16. Rowbotham M, Harden N, Stacey B, et al. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA. 1998;280:1837–1842. 17. Rice ASC, Maton S, Postherpetic Neuralgia Study Group. Gabapentin in postherpetic neuralgia: a randomised, double blind, placebo controlled study. Pain. 2001;94:215–224. Clinical Interventions in Aging 2009:4