Treating neuropathic pain

Currently, the treatment of neuropathic pain involves the use of:

• antidepressants,
• anticonvulsants,
• tramadol,
• opioids,
• local anesthetics.

European recommendations for the treatment of neuropathic pain

State of the problem

• Neuropathic pain is widespread in the population
• Neuropathic pain often reaches a high degree of intensity
• Neuropathic pain is often associated with comorbid disorders (depression, anxiety, sleep disorder), high disability, decreased quality of life, impaired ability to work

Neuropathic pain is unsatisfactorily diagnosed and treated in therapeutic practice.

Medical Tactics

• Carefully listen to the patient (words-descriptors of neuropathic pain);
• Assess the type of pain (neuropathic, nociceptive, combined, neither one, nor another);
• Diagnosis of the disease that led to the onset of neuropathic pain and its treatment, if any;
• Development of a treatment strategy focused on reducing pain, increasing the patient's functional capabilities, improving the quality of life;
• Treatment should begin as early as possible and be active.

Diagnosis of Neuropathic Pain

Use of screening methods to identify signs of possible neuropathic pain. Criteria for neuropathic pain:

• The localization of pain corresponds to anatomical zones of innervation;
• Clinical examination reveals sensory disorders (at a touch, needle prick, thermal, cold stimuli);
• The cause of neuropathic pain is established (by clinical or instrumental methods).

Pharmacotherapy is the main method of treatment of neuropathic pain.

Principles of pharmacotherapy are:

• Definition of the drug for treatment and its discharge;
• Informing the patient about the disease, treatment tactics, possible adverse events, duration of treatment;
• Control the patient's compliance with doctor's prescriptions. 50

Painful polyneuropathy (pain polyneuropathy is excluded after chemotherapy and HIV-polyneuropathy)

• The effectiveness of: tricyclic antidepressants (TCAs), duloxetine, venlafaxine, pregabalin, gabapentin, opioids, tramadol (level A);
• NNT *: TCA = 2.1-2.5, venlafaxine = 4.6, duloxetine = 5.2, pentin = 3.9, opioids = 2.6, tramadol = 3.4; I
• e shows: capsaicin preparations, mexiletine, oxcarbazeprin, SSRIs, topiramate (level A), memantine, mianserin, topically clonidine level B); inconclusive / inconsistent results: carbamarin, valproate, SSRIs.

Recommendations:

• TCAs, pregabalin, gabapentin (first-line drugs);
• IOPI - second-line drugs (in the absence of risk of cardiac complications);
• Tramadol or strong opioids are third-line drugs
• NNT - Number Needed to Treat. The indicator, which is the ratio of the number of patients in the study to the number of patients with a 50% or more reduction in the intensity of pain. The lower the NNT rancitor, the more effective the treatment.

Postherpetic neuralgia

• The efficacy of TCAs, pregabalin, gabapentin, opioids (level A) has been demonstrated;
• Probably effective: lidocaine topically, tramadol. Valproate. Capsaicin topically (level B);
• NNT: TCA = 2.6, pregabalin = 4.9, gabapentin = 4.4, opioids = 2.7, tramadol = 4.8, valproate = 2.1;
• Not recommended: NMDA antagonists, mesitylene, lorazepam (level A).

Recommendations:

• TCA, pregabalin, gabapentin - first-line drugs;
• Lidocaine is local (especially in the elderly and in the presence of allodynia);
• Strong opioids are second-line drugs.

Trigeminal neuralgia

The effectiveness of carbamazepine (level A), NNT = 1.8; Probably effective oxcarbazepine (level B);

• Other drugs (baclofen, lamotrigine) can be prescribed only if carbamazepine or oxcarbazepine is ineffective or undesirable surgical treatment,
• Not recommended: eye drops with anesthetics (level A).

Recommendations:

• Carbamazepine 200-1200 mg per day or Oxcarbazepine 600-1800 mg per day;
• In medicamentous refractory cases - surgical treatment.

Central Neuropathic Pain

Central post-stroke pain, pain after spinal trauma:

• Probably effective: pregabalin, lamotrigine, gabapentin. TCA (level B)
• Not recommended: valproate, mexiletine (level B).

Neuropathic pain in multiple sclerosis:

• Cannabinoids (level A) are recommended only in case of ineffectiveness of other medicines.
• Pregabalin - for central pain:
• Cannabinoids for pain in multiple sclerosis.
• Radical pain in the back: there are no randomized clinical trials;
• Post-operative / post-traumatic neuropathic pain: very few studies;
• Complex regional syndrome of type 2: there are no randomized clinical trials.
• Neuropathic pain with an infiltrative tumor: gabapentin or amitriptyline in addition to opioids,
• Post-traumatic / post-operative neuropathic pain: amitriptyline or venlafaxine;
• Phantom pain: gabapentin or morphine (?);
• Guillain-Barre Syndrome: gabapentin.

Evaluation of treatment effectiveness

1. Clinical significance has a pain reduction of more than 30%;
2. Reduction of the phenomena accompanying neuropathic pain (patient interview, evaluation of allodynia during repeated visits);
3. Improve sleep and mood;
4. Improvement of functions (when asking a patient for clarification, what he can do, assess the behavior and actions of the patient at a doctor's appointment);
5. Improving the quality of life;
6. Possible side effects.

Par. 1,2,3,4,5 - item 6 = general satisfaction. If the drug is ineffective, neurostimulation is indicated.