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Prompt initiation of medications for reflex sympathetic dystrophy (RSD) is very important, especially if the pain is intense, in order to enable the patient to proceed with physical therapy. During the course of treatment, medication doses may have to be adjusted to achieve optimal pain relief and to facilitate the patient's cooperation and participation in physical and occupational therapy. There is a shortage of information regarding effective pharmacotherapy for RSD due to limited numbers of randomized controlled trials. Most medications are prescribed based either on anecdotal evidence (patients have reported that a particular medication was effective for them) or based on studies that have shown that particular medications are effective for other neuropathic pain conditions such as peripheral neuropathy or trigeminal neuralgia.

There are no guidelines available regarding first-line medication for RSD. As a result, there is typically an initial trial-and-error period until the most effective medication is found. At that point, there may be a period of several adjustments until the correct dose is determined. Direct comparisons of the efficacy of drug therapy vs. other therapies such as physical therapy alone, nerve blocks, or spinal stimulation have not yet been investigated.

There are various classes of drugs that may be used for the treatment of RSD including:

• Analgesics
• Anticonvulsants
• Antidepressants
• Bisphosphonates
• Muscle relaxants
• Adrenergic active drugs
• Steroids
• Opioids

Analgesics (Pain Medications)

• Aspirin
• Acetaminophen
• Non-steroidal anti-inflammatory drugs (NSAIDs)

Side effects include:

• Nausea/vomiting
• Diarrhea
• Constipation
• Thinning of the blood (aspirin)

Anticonvulsants

A variety of anticonvulsants have been used in RSD patients to provide pain relief including: * Phenytoin (Dilantin) * Gabapentin (Neurontin) - this medication has been proven effective in clinical trials for neuropathic pain. Although there are no clinical trials showing efficacy for RSD, there is sufficient anecdotal evidence for pain relief that gabapentin is recommended by clinicians for treatment of RSD. * Carbamazepine (Tegretol)

Side effects of anticonvulsants include:

• Dizziness
• Drowsiness
• Nausea/vomiting
• Abnormalities of blood or platelet counts
• Abnormalities of liver function

Antidepressants

Tricyclic antidepressants may be very effective for RSD based on anecdotal evidence, however, they carry a risk of intentional overdose. Selective serotonin reuptake inhibitors (SSRIs) are not as prone to overdose however, they are also not as effective for the treatment of pain in RSD.

Tricyclic antidepressants that may be used in the treatment of RSD include:

• Amitriptyline (Elavil)
• Doxepin (Sinequan, Adapin)
• Nortriptyline (Pamelor, Aventyl)

Selective serotonin reuptake inhibitors (SSRIs) that may be effective for treatment of RSD include:

• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Paroxetine (Paxil)

Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) have been shown to be effective in relieving chronic neuropathic pain and may be effective for RSD as well. They include:

• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)

Side effects of antidepressants include:

• Nausea/vomiting
• Dry mouth
• Urine retention
• Sleep disruption
• Weight gain
• Anxiety

Bisphosphonates

Bisphosphonates target bone loss and have been studied more thoroughly than any other drugs for the treatment of RSD. Bisphosphonates that have undergone clinical trials include:

• Calcitonin (intranasal spray), administered in both nostrils, has been demonstrated to be an affective treatment for RSD pain.