Neuropathic pain - lecture 7 - Dr. Klucken

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VASUpharm14
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Neuropathic pain - lecture 7 - Dr. Klucken
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2013-04-08 18:15:31
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pain pain go away Understand the pathophysiology of neuropathic pain  Recommend appropriate pharmacologic options for neuropathic pain management  Understand the pros and cons of the various treatment options
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  1. neuropathic pain sx
    burning, tingling, shock-like, shooting pain
  2. etiology of neuropathic pain
    • nerve damage 
    •  - enhanced sensory transmission (increased sensitivity, spontaneous)
    • loss of modulatory pain inhibition
    • PAIN DOES NOT CORRELATE WITH DEGREE OF NERVE DAMAGE
    • infection, trauma, metabolic comorbidities, chemo, tumor infiltration, surgery, neurotoxins, nerve compression, inflammation
  3. positive symptoms of neuropathic pain
    • HYPER algesia
    • Allodynia
  4. negative symptoms of neuropathic pain
    sensory deficits, weakness, reflex changes
  5. First-line treatment for neuropathic pain (3)
    • 1. antidepressants (TCAs, SNRIs)
    • 2. anticonvulsants
    • 3. local anesthetic - topical
    • reduce 30-50%
    • APAP/NSAIDs ineffective!
  6. first-line tx for neuropathic pain: antidepressants
    • TCAs - AND - amitriptyline, nortriptyline, desipramine
    • START LOW, GO SLOW
    • takes 6-8 weeks
  7. AE: TCAs
    • anticholinergic
    • CV (tachy/arrhythmias)
    • CNS (dizzy/drowsy)
    • fatal in overdose
  8. first-line tx for neuropathic pain: antidepressants
    • SNRIs
    • 1. Venlafaxine (Effexor/Effexor XR)
    • takes 6 weeks
    • 2. duloxetine (Cymbalta)
    • 60 mg, avoid renal/hepatic dysfunction
  9. AE: venlafaxine (Effexor, Effexor XR) (3)
    • 1. increased BP (>300 mg daily)
    • 2. insomnia
    • 3. serotonin syndrome
  10. first-line tx for neuropathic pain: anticonvulsants (pearls)
    • prolong depolarization, reduce neuronal firing
    • 1. Gabapentin (Neurontin) - TID
    • 2. Pregabalin (Lyrica) TID
    • 3. Carbamazepine (Tegretol) 
    • 4. Valproate
  11. AE: Gabapentin (Neurontin)
    • sedation/dizziness (start low, go slow)
    • renal dosing
  12. AE: Pregabalin (Lyrica)
    renal dosing
  13. AE: Carbamazepine (Tegretol)
    • increased ADRs: sedation, N/V, blurred vision, etc.
    • blood dyscrasias (monitor CBC)
    • CYP DDI (auto-inducer)
  14. AE: Valproate
    • weight gain
    • rash
    • GI upset
  15. first-line tx for neuropathic pain: lidocaine 5% topical patch (Lidoderm)
    • MOA: block Na channels
    • prolong depolarization
    • dosing: up to 3 patches daily (INTACT SKIN)
    • 12 on/12 off hours (tachyphylaxis)
    • minimal systemic ADRs
  16. first-line tx for neuropathic pain: Capsaicin
    • local anesthetic
    • MOA: depletes substance P from nociceptors
    • dosing: QID (INTACT SKIN)
    • repeated/continuous application for weeks
    • minimal system ADRs: wash hands, burning initially
  17. Tx for neuropathic pain not first line
    • opioids
    • use: refractory pain, combo with other therapies
    • 1. methadone
    • 2. tramadol
  18. MOA: binds NMDA receptor 
    hint: opioid
    methadone
  19. MOA: centrally acting analgesic
    binds mu-opioid and inhibits NE/5HT reuptake
    hint: opioid
    • tramadol
    • dosing: q4-6hr
    • PRECAUTIONS: avoid use with SEIZURE history, risk of SEROTONIN SYNDROME, Renal dosing

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