neuropathic pain - a palliative care approach dr reema patel staff grade in palliative medicine
TRANSCRIPT
Neuropathic Pain - A Palliative Care Approach
Dr Reema Patel
Staff Grade in Palliative Medicine
Content
• Introduction
• Pathophysiology of neuropathic pain
• Management of neuropathic pain– The evidence– What to do in Clinical practice
What is Palliative Care?
• The active, total care offered to a patient and their families, when it is recognised that their illness is no longer curable
• It concentrates on the quality of life and alleviation of distressing symptoms within the framework of a coordinated service
WHO Classification
What is pain?
• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage”
Merksey 1979
• It is a subjective feeling, rather than objective
Why is neuropathic pain important?
• Relatively common and can be difficult to treat
• 34% of cancer patients referred to pain service (Grond 1999)
• 30% of lung cancer patients (Potter 2004)
• Up to 40% of all cancer-related pain may have a neuropathic mechanism involved (Caraceni 1999)
Definitions• Neuropathic pain
– Pain initiated or caused by a primary lesion/dysfunction in the nervous system
• Neuralgia– Pain in the distribution of the nerves
• Analgesia– Absence of pain in response to stimulation which would
normally be painful
• Allodynia– Pain due to a stimulus that does not normally provoke pain
• Hyperalgesia– Increased response to stimulus that is not
normally painful
• Noxious stimulus– One which is damaging to normal tissue
• Nociceptors– Receptor preferentially sensitive to noxious
stimulus (thermal, chemical or mechanical)
What is normal - how is pain conveyed?
• Nociceptors - connect to nerve fibres and carry sensation of pain to the dorsal horn in the spinal cord
• These signals then cross the spinal cord and are transmitted to the brain in the spinothalamic tract
Normal Pain Pathways
Nerve fibres
• A fibres - small diameter, myelinated
• C fibres - small diameter, unmyelinated
• A fibres - large diameter, myelinated(Fordham 1986)
A fibres
• Mainly found in or just under the skin
• Activated by noxious stimuli– Intense heat, cold, mechanical and
chemical
• Fast or first pain
C fibres
• Usually in a single receptive area
• Convey messages generated by damaged tissue
• Slow or second pain
A fibres
• Responds to light touch or mechanical stimulation (mechanoreceptors)
• Vibration, touch and pressure
• Not normally unpleasant
• As a rule, C fibres are opioid sensitive and A fibres are not
What happens in neuropathic pain?
• The nerve fibres are damaged or dysfunctioning
• This causes over activity of the nerve (even after noxious stimulation has gone)
Pathophysiology
• The nerve can generate impulses randomly and “fire-off’
• There is failure or reduction of the usual inhibitory mechanisms (disinhibition)
• The brain and spinal cord may become unusually sensitive (central sensitisation) to the nerve impulses (NMDA involved in this)
Causes of nerve damage
• Peripheral
• Central(Scadding 2003)
Peripheral causes
• Trauma - post thoracotomy• Diabetes• Nutritional - alcoholic• Drugs - Cisplatin, Isoniazid• Infective - Guillain Barre• Direct infiltration - Pancoast’s tumour
Central causes
• Spinal cord compression
• Multiple Sclerosis
• Intrinsic spinal cord tumours and syringomyelia
• Spinal root - disc prolapse, trigeminal neuralgia
How does it feel?
• Can be difficult to describe
• ‘Shooting,’ ‘burning,’ ‘toothache,’ electrical impulse’
• Often in one set place
• Can follow the path of the affected nerve (common in root pain from spinal cord compression)
How do we treat it?
• Often with multiple treatment modalities
• Multidisciplinary team approach is also valuable in complex pain
Treatment modalities
• Psychological
• Spinal (epidural or intrathecal)• Surgery (decompression)• Block (nerve, plexus, root)
• Pharmacological• TENS• Topical
TENS
• Transcutaneous Electrical Nerve Stimulation
• Works in 2 ways– Electrical impulses stimulate A fibres
(mechanical)• A fibre activity is greater than A and C fibre
‘pain’ activity, thereby closing the ‘pain gate’– Stimulates the body to release its own natural pain
killers (endorphin and enkephalin)
Gate theory of pain (Melzack and Wall)
• Stimulating large A fibres can inhibit pain response via interneuron.
What drugs do the Palliative Care Physicians use?
• Recent questionnaire to doctors on the Specialist Register for Palliative Care (2005)
• ‘What are your choices for managing NP in palliative care?’
• Asked to give 1st, 2nd and 3rd line choices
• To state maximum dose used
Results
• 82 questionnaires sent out
• 68% reply rate
Most popular drugs
1. Gabapentin
2. Amitriptyline
3. Ketamine
4. Methadone
5. Dexamethasone
6. Clonazepam
(excluding opioids other than methadone)
Summary of anti-neuropathic agents
• Pharmacokinetics• Dosing• Evidence
1. Gabapentin
• Calcium channel blocker• It is excreted unchanged by the kidneys and
hence accumulates in renal failure• Doses
– Rapid• 300mg OD day 1, BD day 2 and TDS day 3, adding
300mg a day as required to 600-1200mg TDS
– Slow• 100mg TDS Day 1, 300mg TDS day 7, 600mg TDS day
14, 900mg TDS day 21
• Gabapentin– Cochrane review, Wiffen 2005– 14 studies included (one study acute pain,
one study cancer-related pain)– NNT = 4.3– Evidence to show that gabapentin is
effective
• Pregabalin– Related to gabapentin– Sabatowski 2004 - large study (192) in
post herpetic neuralgia– Significant response Vs placebo at 2 dose
levels: 150mg/d and 300mg/d
2. Amitriptyline
• Tricyclic antidepressant
• Blocks pre-synaptic reuptake of serotonin and noradrenaline
• Dose– 10mg ON initially, increasing to 150mg ON
over 7-8 weeks
2. Amitriptyline
• 1996 systematic review McQuay et al– 17 RCTs– NNT for TCAs = 2.9– SSRI are less effective that TCAs – Efficacy in burning Vs shooting pain not
supported
3. Ketamine
• Partial NMDA antagonist
• Useful in neuropathic, inflammatory or ischaemic pain
• Can also be useful in terminal uncontrolled pain
Ketamine
• Routes– PO
• 10mg QDS and increase by 10mg increments OD to BD up to 50mg QDS
– CSCI (continuous sub-cut infusion) - • 50-100mg/24 hours, increasing by 50-100mg every 72
hours up to 500mg/24hrs
Always co-prescribe an antipsychotic, either haloperidol or midazolam due to the common S/E of dysphoria
NMDA antagonists - Ketamine
• Cochrane review, Bell 2003– 2 RCTs of adults with cancer pain on
opioids receiving ketamine– Mercadante 2000 - in cancer NP; 10
patients unrelieved by morphine, given IV ketamine with significant pain relief. 6 patients suffered central adverse effects
4. Methadone
• Opioid that acts as a NMDA receptor antagonist + serotonin re-uptake inhibitor
• Long and variable half life• Inactive metabolites therefore lower toxicity in
renal failure• Faecally excreted• Can take up to 10 days to reach steady state
When to use methadone
• Pain partially responsive to morphine
• Renal failure
• Morphine tolerance
Specialist prescribing + requires hospital admission
Conversion of methadone
• Stop all opioids• Loading dose: 5 to 10% of the 24hour
PO morphine or equivalent, to a max of 30mg
• Same dose as PRN but 3hourly• On day 6, add total dose of methadone
in last 24hours and give 12hourly
Conversion of methadone
• Dose changes are at a percentage increment as for morphine every 4-6 days
• Re-assess as accumulation can occur up to 10days after commencing/dose changing
• CSCI - half the dose and dilute (very acidic)• Can exacerbate asthma and can cause a
diuresis
Methadone
• Nicholson systematic review 2004– Cancer pain (not NP specifically)– 8 studies– ‘Not possible to draw conclusions on
relative merits of methadone compared to other opioids in the management of NP pain’
5. Dexamethasone
• Steroid
• Used as adjunct for acute NP
• Anti-inflammatory
• Dose - 6 to 12 mg daily
6. Clonazepam
• Benzodiazepine• GABA potentiating actions in CNS, notably
spinal cord, hippocampus, cerebellum and cerebrum
• Reduces neuronal activity
• Dose– 500mcg ON increasing to 4mg(half life 20-60hours)
Conclusions drawn
• Large number of different agents used
• Lack of concurrence particularly after 1st/2nd line choices
• Maximum doses of drugs were low (when compared to evidence)
• Evidence based on non-cancer, peripheral NP pain models
What about opioids?
Multiple mechanisms of pain• Used in conjunction with classical NP drugs• Kalso 2004 systemic review (15 RCTs)
– Mean decrease in pain intensity in most studies was at least 30% both for NP and musculoskeletal pain
– Opioids included oxycodone, morphine, methadone and fentanyl
Therefore always worth trying opioids
In clinical practice
• Are neuropathic mechanisms present?– Pain in area of altered sensation– Rapidly escalating doses of opioids with no
significant improvement in pain– S-LANSS questionnaire
Leeds Assessment of symptoms and signs - self report (S-LANSS)
• Scored out of 24• Scores of 12 or more are strongly suggestive
of neuropathic pain• Questionnaire has been validated in The
Journal of Pain (Bennett M et al (2001, 2005)
What can you do?
• Identify NP (hx/ S-LANSS)• Think about WHO pain ladder initially (esp. if multiple
mechanisms of pain)Non opioid, weak opioid, strong opioid
If non-opioid responsive, or clearly NP process:• If mild pain and no CI, AMITRIPTYLINE• If moderate to severe pain, GABAPENTIN • Consider DEXAMETHASONE at the same time• If pain continues refer for specialist input
Any Questions?