neurologic disorders
Neuropathic Pain
Treatment of Neuropathic Pain
Multimodal therapy (eg, physical methods, antidepressants, antiseizure drugs, psychotherapeutic methods, neuromodulation, sometimes surgery) Successful neuropathic pain management starts with confirming the correct diagnosis and managing treatable causes (eg, Cervical Herniated Nucleus Pulposus , Neuromodulation (spinal cord or peripheral nerve stimulation) is particularly effective for neuropathic pain. Several classes of drugs are effective (see table Drugs for Neuropathic Pain ), but complete relief is unlikely, and setting realistic expectations is important. The goal of pharmacologic management is to lessen neuropathic pain so that it is less debilitating. Opioid Analgesics can provide some relief but are generally less effective than for acute nociceptive pain and are associated with risk of dependence; adverse effects may prevent adequate analgesia. , such as antidepressants and antiseizure drugs, are most commonly used to treat neuropathic pain, and their efficacy is supported by randomized trial data ( Treatment reference ; see table Gabapentinis one of the most widely used drugs for such purposes. For effective analgesia, the dose should usually be > 600 mg orally 3 times a day, and many patients need a higher dose. Maximum dosage is usually considered to be 1200 mg orally 3 times a day. Pregabalinis similar togabapentinbut has more stable pharmacokinetics; dosing 2 times a day is as efficacious as dosing 3 times a day and results in better compliance. The dosing goal is at least 300 mg/day orally (eg, a starting dose of 75 mg 2 times a day, increased to 150 mg 2 times a day within 1 week). Neuropathic pain syndromes may require up to 600 mg/day. Some patients who do not respond well to or do not tolerategabapentindo respond to or toleratepregabalinand vice versa, even though the two drugs have a similar primary mechanism of action (binding to the alpha-2 delta ligand of the presynaptic calcium channel, which modulates nociceptive signaling). Fortricyclic antidepressants(amitriptyline,nortriptyline,desipramine), the primary mechanism of action is blocking the reuptake ofserotoninandnorepinephrine. Analgesic doses (75 to 150 mg orally once a day) are usually insufficient to treat depression or anxiety. Anticholinergic and adrenergic adverse effects often limit effective dosing. Secondary amine tricyclic antidepressants (nortriptylineanddesipramine) have a more favorable adverse effect profile than tertiary amine tricyclic antidepressants (amitriptyline). ) reuptake inhibitor, which appears to be effective for diabetic neuropathic pain, Fibromyalgia , chronic musculoskeletal pain (including Venlafaxine'seffects and mechanism of action are similar to those ofduloxetine. Topical drugs and alidocaine-containing patch may be effective for peripheral syndromes. Other potentially effective treatments include Spinal cord stimulation by an electrode placed epidurally for certain types of neuropathic pain (eg, chronic leg pain after spine surgery) Electrodes implanted along peripheral nerves and ganglia for certain chronic neuralgias (peripheral nerve stimulation) Sympathetic blockade, which is usually ineffective, except for some patients with complex regional pain syndrome Neural blockade or ablation (radiofrequency ablation, cryoablation, chemoneurolysis) Electrical stimulation (TENS) 1.Finnerup NB, Attal N, Haroutounian S, et al: Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis.Lancet Neurol14 (2):162–173, 2015. doi: 10.1016/S1474-4422(14)70251-0 