neuropathic pain. types of pain nociceptive pain an appropriate physiologic response to painful...
TRANSCRIPT
Neuropathic pain
Types of Pain
Nociceptive Pain
An appropriate
Physiologic
response
to painful stimuli
Neuropathic Pain
An inappropriate
response caused
by a dysfunction
in the nervous
system
Signs of Neuropathic Pain
Hyperalgesia
An increased
response
to a stimulus that is
normally painful
Allodynia
Pain due to a
stimulus that is
not normally painful
Symptoms of Neuropathic Pain
ปวดแสบปวดร้�อน
ปวดแปล๊�บๆเป�นพั�กๆ
ปวดแบบไฟช้�อต
เจ็�บมากกว�าปกต�
เจ็�บไม�ม�สาเหต จ็�!ดๆ จ็�อดๆ
Nerve Pathways and Types of Pain
Afferent FibersAfferent FibersAfferent FibersAfferent Fibers
C and AC and AC and AC and A
AAAA
SpontaneousSpontaneousSymptoms Symptoms SpontaneousSpontaneousSymptoms Symptoms
Burning/Burning/pricking painpricking painBurning/Burning/pricking painpricking pain
Dysesthesias/Dysesthesias/paresthesias paresthesias Dysesthesias/Dysesthesias/paresthesias paresthesias
Stimulus-Stimulus-Evoked Evoked
SignsSigns
Stimulus-Stimulus-Evoked Evoked
SignsSigns
HyperalgesiaHyperalgesiaHyperalgesiaHyperalgesia
AllodyniaAllodyniaAllodyniaAllodynia
Types of Neuropathic Pain Syndromes
Post-herpetic neuralgia (PHN)
Diabetic neuropathy
Complex regional pain syndromesReflex sympathetic dystrophy
Causalgia
Phantom limb pain
Trigeminal neuralgia
Medical History
Central Effects
Stroke
Spinal cord lesions
Multiple sclerosis
Tumors
Peripheral Effects
Trauma, viral infections, vascular disease, metabolic disturbances
Surgical procedures
Exposure to toxins, drugs, or alcohol
Nutritional deficiency
Neurotransmitters Involved in Pain Pathways
Serotonin
GABA
Glutamate
Substance P
Opioid peptides
Reisine T, Pasternak G. In: Goodman & Gilman’s. 9th ed. 1996;521-555.
Ollat H, Cesaro P. Clin Neuropharmacol.1995;18:391-404.
Central Reorganization of A FibersCentral Reorganization of A Fibers
Allodynia
Mannion RJ, Woolf CJ. Clin J Pain 2000
Signs and symptoms
Symptoms Pain descriptors: Electric ไฟช้�อต Burning แสบร้�อน Icy cold เย็�นวาบ Frostbite แมล๊งก�ด แมล๊งไต� Aching ปวดต$%อ Tingling ย็ บย็�บ Needles and pins ม�เข็�มทิ่�(ม Onset of pain delayed after injury
สาเหตุ�ที่�พบบ�อยของ neuropathic pain
ปวดหล๊�งจ็ากเป�นง)สว�ดปวดเส�นปร้ะสาทิ่หน�าไม�ทิ่ร้าบสาเหต (Trigeminal neuralgia)
เบาหวานส ร้าโล๊หะหน�ก สาร้หน) ตะก�(ว ปร้อทิ่ Thallium
ไม�ทิ่ร้าบสาเหต
• โร้คเส�นปร้ะสาทิ่ แล๊ะร้ะบบปร้ะสาทิ่อ$(นๆGuillain-Barre syndrome
• Multiple sclerosis• Post stroke pain• Traumatic
Carpal tunnel syndrome Cervical or lumbar radiculopathy Complex regional pain syndrome Spinal cord injury Stump pain
ยาที่�ใช้�ประจำ�า ย็าความด�น hydralazine
ย็าว�ณโร้ค isoniazid ย็าฆ่�าเช้$%อ metronidazole ย็าก�นช้�ก phenytoin ย็าเคม�บ/าบ�ด paclitaxel vincristine
cisplatinum ว�ตาม�น B6 เก�นข็นาด
ย็าต�านโร้คเอดส0d4T (stavudine) ddC (zalcitabine) ddI (didanosine)
สาเหตุ�ที่�พบบ�อยของ neuropathic pain
First line medicationTramadol hydrochloride
Tricyclic antidepressants Amitriptyline
Nortriptyline
Desipramine
Bitartrate
Acetaminophen,
Aspirin,
Ibuprofen
Second line medication
ย็าก�นช้�กLamotrigine
Carbamazepine
ยาตุ�านโรคซึ�มเศร�าBupropion hydrochloride
Citalopram
Paroxetine
Venlafaxine hydrochloride
Imipramine hydrochloride
Beyond Second line medication
capsaicin
clonidine
dextromethorphan
mexiletine
MAJOR OUTCOMES CONSIDERED
ล๊ดปวดได�ด�ปล๊อดภั�ย็ไม�แพั�ย็า ไม�ร้บกวนร้ะด�บย็าอ$(นได�ค ณภัาพัช้�ว�ตทิ่�(ด�ข็2%นร้าคาถู)ก ค �มค�า
Table 3Benefit-Risk Analysis of Agents Used to Treat Neuropathic Pain
Medication Number of Patients Needed to Treat (NNT)
for Efficacy/Adverse Effects
Painful/DiabeticNeuropathy
Postherpetic Neuralgia
Peripheral Nerve Injury
TrigeminalNeuralgia
Tricyclic antidepressants Amitriptyline Desipramine
2.4/4.92.0/9.73.4/20
2.3/62.3/6.2
1.9/4.8
2.5/ND2.5/ND
———
SSRIs Paroxetine Citalopram
6.7/ND2.9/ND7.7/ND
———
———
———
Phenytoin 2.1/9.5 — — —
Carbamazepine 3.3/1.9 — — 2.6/3.4
Gabapentin 3.7/1.8 3.2/3.4 — —
Lamotrigine — — — 2.1/ND
Mexiletine 10.0/6.3 — — —
Baclofen — — — 1.4/ND
Tramadol 3.4/ND — — —
Oxycodone — 2.5/ND — —
Source: References 15,21,22,26,27,30-32,37
GABAPENTIN
NEURONTIN®
VULTIN
Pharmacologic properties of Gabapentin
Increases GABA in brain, possibly by enhancing rate of synthesis from glutamateBinds to specific site localized to brain regions associated with major excitatory inputsInhibits sodium currents by mechanism distinct from phenytoin and carbamazepineInhibits branched-chain amino acid transferase, possibly reducing glutamate concentrationNo effect on GABAA or GABAB receptors
GBP& PGB Binds to the 2 Subunit of
Voltage-gated Ca2+ Channels in the Brain
Noradrenaline
Glutamate
Substance P
Modulates neurotransmitter release e.g.
Postsynaptic
Neurotransmitter Binding Site
Presynaptic
Voltage- Gated
Ca2+channel
2 Subunit
Neurotransmitter Transporter
Neuropathic Pain:
Treatment of Neuropathic pain in
adults age 18 years and above
Indication
Dose regimen
Method of administration:
Initial Titration
Dose Day1 Day2 Day3
900mg 300mgQD 300mgBID
300mgTID
Increase if necessary, based on response, up to a maxi
mum dose of 3600mg/day (given as three equally divid
ed doses)
Adverse Events
Somnolence, dizziness, ataxia, fatigue, nystagmus which were generally mild to moderate with a median duration of 2 weeks
5% Lidocaine Patch
Treatment with the 5% lidocaine
no more than 3 patches daily for a maximum of 12 hours, US FDA-approved dosage for post-herpetic neuralgia).
Tricyclic Antidepressants
analgesic effect that has been demonstrated to be independent of their antidepressant effectTCAs should be initiated at low dosages
10 to 25 mg hs titrated every 3 to 7 days by 10 to
25 mg/d as tolerated
Tricyclic Antidepressants
Contraindications
especially in patients with cardiovascular disease
risks of conduction defects, arrhythmias, tachycardia, stroke, and acute myocardial infarction.
Tramadol
a norepinephrine and serotonin re-uptake inhibitor
a major metabolite that is a mu-opioid agonist
initiated at low dosages 50 mg once or twice daily
titrated every 3 to 7 days by 50 to 100 mg/d in divided doses as tolerated.
maximum dosage 100 mg 4 times daily
(> 75 years, 300 mg/d in divided doses)
Opioid Analgesics
Opioid Analgesics: Numerous short- and long-acting opioid analgesics are available. begin with short-acting opioid analgesics
morphine sulfate 5 to 15 mg every 4 hours as needed.
Second line drug
Lamotrigine has results of multiple randomized controlled trials for
human immunodeficiency virus (HIV) sensory neuropathy
painful diabetic neuropathy (PDN)
central post stroke pain
incomplete spinal cord lesions from spinal cord injury
CarbamazepineWell-established beneficial effect for trigeminal neuralgia
Approved by the FDA for the treatment of this neuropathic pain syndrome
In patients with painful diabetic neuropathy, some evidence exists for a beneficial effect of carbamazepine, but results from studies of phenytoin are inconsistent
Lamotrigine
The guideline developers do not consider lamotrigine a first-line treatment for neuropathic pain
The slow and careful titration required and the risk of both severe rash and Stevens-Johnson syndrome associated with its use.
Simple pregabalin dosing in neuropathic pain
• bd (twice daily) dosing
• The dose most often used in open-label studies was approximately 300 mg/day
• Clear dose-response relationship
• May be taken with or without food
• Dosage reduction is necessary in patients with renal impairment
Data on file, Pfizer Australia. LYRICA Approved Australian Product Information.
Pregabalin: Recently Defined Mechanism
Binds to neurons at the - subunit of voltage-
gated calcium channels (brain and spinal cord)
Attenuates calcium influx into depolarized nerve terminals
Reduces excitatory neurotransmitter release from hyperexcited neurons (e.g. glutamate, Substance P,noradrenaline)
No GABA activity
- mechanism of action may be relevant for
both peripheral neuropathic pain and epilepsy**Clinical significance of these pharmacologic effects of pregabalin in humans is not known.
Pregabalin post-herpetic neuralgia and painful
diabetic neuropathy has a combined NNT for doses
ranging from 150 to 600 mg of 4.2 (3.4–5.4) comparable to the effect of gabapentin.
NNH = 11.7 (8.3-5.4)
Algorithm for Neuropathic pain treatment:
An Evidence based Proposal
Results
105 randomized, double-blind, placebo-controlled studies were included.
39 anticonvulsants,
26 antidepressants,
11 opioids,
7 NMDA antagonists,
9 mexiletine, 4 topical lidocaine,
3 cannabinoids, 11 capsaicin, and
1 glycine antagonist.
The trials included patients with central post-stroke pain, spinal cord injury pain, multiple sclerosis, painful polyneuropathy, post-herpetic neuralgia, phantom limb pain, post-mastectomy and postsurgical pain, brachial plexus
avulsion, trigeminal neuralgia, HIV-neuropathy, Mixed neuropathic pain conditions.
Results
Tricyclic antidepressants relieve central post-stroke pain, post-
herpetic neuralgia, painful diabetic and non-diabetic polyneuropathy and post-mastectomy pain syndrome,
but not spinal cord injury pain, phantom limb pain, or pain in HIV-neuropathy.
NNT ranges from 2 to 3. NNH is 14.7 (10.2–25.2)
carbamazepine
do not meet current methodological standards
(e.g. use of validated outcome measures, sample size calculation, and adequate description of randomization procedure, statistical methods, and patient flow)
Phenytoin
positive effect on painful diabetic neuropathy in one trial NNT: 2.1 (1.5–3.6)
while another showed no analgesic effect.
Valproate in three parallel group trials had high efficacy in
relieving pain in painful diabetic neuropathy and post-herpetic neuralgia with very low NNTs,
while a crossover trial found no difference between valproate 1500 mg and placebo in treating painful polyneuropathy and diabetic neuropathy.
not significantly better than placebo in relieving pain in patients with spinal cord injuries.
Gabapentin Studied in several large trials Moderate effect on pain and quality
of life measures including mood and sleep disturbance in mixed neuropathic pain states, post-herpetic neuralgia, painful diabetic neuropathy, and spinal cord injury.
Gabapentin
NNT is 5.1 (4.1–6.8) (over all NNT including all condition, high and low dose) but excluding 900mg/d in mixed
neuropathic pain and including 2400mg/d, The NNT is 3.8 NNH for withdrawal for gabapentin is 26.1
(14.1–170).
Gabapentin
gabapentin plus venlafaxine improved pain and quality of life compared with gabapentin plus placebo in painful diabetic neuropathy .
Lamotrigine
pain relieving effect in trigeminal neuralgia as an add-on treatment (NNT: 2.1 (1.3–6.1)),
in painful diabetic neuropathy (NNT: 4.0 (2.1–42)), and in central post-stroke pain.
Lamotrigine In HIV neuropathy, a small study
showed a significant effect (300 mg/d), but an extended larger study (600 mg/d) only demonstrated an effect on some patients receiving neurotoxic antiretroviral therapy.
In spinal cord injury pain:had no effect.
Topiramate
failed to relieve pain in three large trials with painful diabetic neuropathy, while another trial found a significant effect (NNT: 7.4 (4.3–28.5)).
four studies had a high withdrawal rate due to side effects (NNH: 6.3 (5.1–8.1)).
Opioids: Tramadol
studied in two trials in painful polyneuropathy and in one trial in post-herpetic neuralgia .
overall NNT of 3.9 (CI 2.7–6.7).
NNH was 9.0 (6.0–17.5).
NMDA antagonists :dextromethorphan studied mainly in small trials in
neuropathic pain, with either no or minor pain relieving effect .
in painful diabetic polyneuropathy (NNT: 2.5 (1.6–5.4)), but seems to lack efficacy in post-herpetic neuralgia.
NNH is 8.8 (5.6–21.1)
Treatment algorithm In choice of treatment for neuropathic pain a set of
different criteria are relevant including: Consistent outcome in high-quality randomized
controlled trials. High degree of pain relief and superiority to existing
treatments. Persistent pain relieving effect. Few and only mild side effects. Effect on quality of life. Low cost.
If only one set of criteria: pain relief is TCA > opioids ≥ tramadol ≥ gabapentin/pregabalin.
If the criteria for efficacy are based on both pain relief and quality of life is
gabapentin/pregabalin > tramadol > opioids > TCA
Occasionally dangerous side effects of TCA and strong opioids need to be considered.
Conclusion
TCAs have lower NNT values than gabapentin/pregabalin but may be due to differences in study design.
Gabapentin/pregabalin have higher NNH values and lack serious adverse effects
TCA and Gabapentin/Pregabalin, these two drug classes as first line treatment of peripheral neuropathic pain.
Conclusion
Tramadol and oxycodone may be considered second or third line drugs
In trigeminal neuralgia, carbamazepine is first choice (consistent outcome with a low NNT), but studies of varying quality. Oxcarbazepine may be an alternative.
Conclusion
Gabapentin/pregabalin MAY be first choice.
TCAs, lamotrigine, cannabinoids, tramadol, and opioids may be second choice.
In the elderly
Conclusion