515: Opioid-Sparing Effect of Escitalopram in Central Post-Stroke Pain with Pancreatic Encephalopathy

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic neuropathic pain, Pharmacological treatments

Background and Aims: The global burden of stroke is expected to increase by 2050, dramatically impacting the vulnerable elderly population in low and middle income countries. Central post-sroke pain is a debilitating complication that is often refractory to pharmacologic interventions, occurring in 0.31% to 30.1% of stroke survivors. The management of central post-stroke pain can become extremely challenging when there is a concomitant metabolic or inflammatory condition, like pancreatic encephalopathy, that complicates the clinical picture by masking neurological changes and cognitive decline and narrowing the therapeutic window for certain analgesics. Escitalopram offers a promising and safer alternative in the elderly, potentially reducing the need for high-dose opioids. While clinical evidence remains limited, this case report highlights the considerable opioid-sparing effect of escitalopram in such clinically complex situations.

Methods: The patient is a 73-year-old male with chronic central post-stroke pain secondary to left thalamic infarct. He was admitted for acute pancreatitis, presenting as new-onset epigastric pain and vomiting. Twenty-four hours post-admission, the patient developed pancreatic encephalopathy, characterized by disorientation and agitation. Prior to admission, the patient was already on fentanyl patch 150 mcg/hr for the management of central post-stroke pain. This was then transitioned to patient-controlled analgesia (PCA) fentanyl starting at 100 mcg/hr basal rate to allow for easier opioid titration while at the hospital. Due to systemic deterioration, the patient was intubated and transferred to ICU. Over the succeeding ICU stay, PCA fentanyl was aggressively uptitrated to 250 mcg/hr. Pregabalin 600 mg/day was resumed to help manage agitation episodes from refractory abdominal and neuropathic pain. Despite this, pain control was still inadequate. Therefore, escitalopram 20 mg/day was initiated approximately one month after admission.

Results: Within 6 days of starting escitalopram 20 mg/day, the patient reported a marked decrease in stabbing and "pins and needles" sensations on the right extremities. A decrease in abdominal pain was also noted. The PCA fentanyl basal was decreased to 200 mcg/hr during this time. The improved analgesia allowed for a 50% reduction in fentanyl basal dose from 200 mcg/hr down to 100 mcg/hr 2 weeks after starting escitalopram. Increased somnolence was evident 3 weeks post-escitalopram initiation, serving as a clinical indicator to further decrease the dose the other co-analgesics. The patient was then discharged on fentanyl patch 100 mcg/hr, morphine 20 mg as rescue dose, pregabalin 500 mg/day, and escitalopram 10 mg/day. On follow up in the pain clinic about 1.5 months on escitalopram, fentanyl patch was successfully tapered down and eventually shifted to morphine 20 mg/day.

Conclusions: The management of central post-stroke pain is an arduous task in itself. This becomes even more notoriously difficult when complicated by acute systemic conditions like pancreatic encephalopathy. In this specific clinical scenario, the introduction of escitalopram proved to be a critical intervention. It not only addressed the seemingly recalcitrant abdominal and central neuropathic pain, but also provided a significant opioid-sparing effect which allowed for the successful de-escalation of high-dose fentanyl. This case suggests that escitalopram can effectively augment pain control and facilitate the weaning of potent narcotics in complex, multi-morbid clinical settings.

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[5] Scuteri, D., Mantovani, E., Tamburin, S., Sandrini, G., Corasaniti, M. T., Bagetta, G., & Tonin, P. (2020). Opioids in Post-stroke Pain: A Systematic Review and Meta-Analysis. Frontiers in pharmacology, 11, 587050. https://doi.org/10.3389/fphar.2020.587050

Presenting Author: Frances Riel B. Elinzano, MD
Submitting Author: Frances Riel Elinzano

Senior Author: Maria Elena Z. Basco-Tiamson, MD

IASP 2026 Global Year theme of Neuropathic Pain: Yes