Professional Documents
Culture Documents
XVIII, Issue 9
November 2010
Editorial Board
Editor-in-Chief
Jane C. Ballantyne, MD, FRCA
Anesthesiology, Pain Medicine
USA
Advisory Board
Michael J. Cousins, MD, DSC
Pain Medicine, Palliative Medicine
Australia
Maria Adele Giamberardino, MD
Internal Medicine, Physiology
Italy
Robert N. Jamison, PhD
Psychology, Pain Assessment
USA
Patricia A. McGrath, PhD
Psychology, Pediatric Pain
Canada
M.R. Rajagopal, MD
Pain Medicine, Palliative Medicine
India
Maree T. Smith, PhD
Pharmacology
Australia
Claudia Sommer, MD
Neurology
Germany
Harrit M. Wittink, PhD, PT
Physical Therapy
The Netherlands
Production
Elizabeth Endres, Associate Editor
Kathleen E. Havers, Programs Coordinator
Karen Smaalders, Marketing and
Communications Manager
Upcoming Issues
Chronic Pain after Injury
Neuropathic Cancer Pain
Dealing with Suering
and more selective TCAs (e.g., nortriptyline) cause fewer anticholinergic effects and less sedation.5 TCAs should be initiated
at low dosages (1025 mg in a single dose at bedtime) and then
slowly titrated as tolerated. Effective dosages vary from one
subject to another (e.g., 25150 mg amitriptyline or equivalent), the average dosage for amitriptyline being 75 mg/day.
Due to substantial pharmacokinetic variability, monitoring of
serum drug concentrations may be helpful in guiding treatment.
SNRI Antidepressants
The efficacy of the serotonin-norepinephrine reuptake inhibitors
(SNRIs) duloxetine and venlafaxine has been established mainly in PDN.7,8 The most frequent adverse events with duloxetine
are nausea, somnolence, dry mouth, constipation, reduced appetite, diarrhea, hyperhidrosis, and dizziness, with discontinuation rates of 1520% across studies. Rare elevations of plasma
glucose, hepatic enzymes, or blood pressure have been reported10; therefore, duloxetine is contraindicated in severe hepatic
dysfunction and in unstable arterial hypertension. Venlafaxine
extended-release is better tolerated than immediate-release, the
main side effects being gastrointestinal disturbances. However,
increased blood pressure and clinically significant ECG changes
reported in 5% of patients with PDN11 may be a concern at high
dosages. Adequate dosages of duloxetine range between 60 and
120 mg/day, with no clear superiority of 120 mg. Treatment
should be initiated at 30 mg/day to avoid nausea and titrated
after 1 week to 60 mg/day.7 Only high doses of venlafaxine
(150225 mg/day) are effective.
Strong Opioids
The use of opioids for the treatment of chronic pain has increased dramatically over the past decade. There has been a
longstanding debate about their efficacy in chronic neuropathic
pain,18 but it is now established that strong opioids (oxycodone,
methadone, and morphine) have efficacy in peripheral neuropathic pain. The evidence is based on several positive randomized controlled trials (RCTs) in PDN and PHN using doses of
oxycodonethe best-studied opioid drug in neuropathic pain
ranging from 10120 mg.7,8,18 However, the doses necessary to
reach efficacy may be higher in neuropathic pain than in nociceptive pain, as indicated by a study comparing the effects
Pregabalin/Gabapentin
The efficacy of gabapentin and pregabalin has been established
in PDN and PHN.8,1214 An extended-release formulation of
gabapentin (1800 mg/day), administered twice a day, has also
been found effective.15 The most common side effects include
dizziness and somnolence, peripheral edema, weight gain, asthenia, headache, and dry mouth. Effective dosages are 1800
3600 mg/day for gabapentin and 150600 mg/day for pregabalin (with inconsistent effects at a dose of 150 mg/day). In
clinical studies, pregabalin is initiated at 150 mg/day, but initial
doses of 75 mg/day at bedtime are recommended to reduce side
effects. Both drugs need individual titration, but the titration
period is generally shorter for pregabalin (increase by 75 mg
every 3 days). Gabapentin is generally administered three times
a day (t.i.d.) except for the extended-release formulation, while
pregabalin can be administered twice a day (b.i.d.).
Topical Lidocaine
The efficacy of topical lidocaine has been established mainly in
PHN. However, based on a meta-analysis, the therapeutic gain
is modest compared to placebo,16 and one recent trial using an
enriched-enrollment design failed to show a difference between
lidocaine and placebo on the primary outcome measure.17 Lidocaine patches are generally safe, with a low systemic absorption,
and only local adverse effects (mild skin reactions) have been
reported.16 Up to four patches per day for a maximum of 12 hours
2
Table 1
Classification of evidence for drug treatments in commonly studied neuropathic pain conditions and recommendations for their use.
Treatments are presented in alphabetical order. Only drugs used in repeated dosages and available or soon to be available for use are
shown here (with the exception of treatments with long-lasting effects such as capsaicin patches). Drugs marked with an asterisk were
found effective in single class II or III studies and are generally not recommended.
Etiology
Diabetic
neuropathy1
Level B Rating
for Efficacy
Level C Rating
for Efficacy
Duloxetine
Gabapentin-morphine
Gabapentin
Oxycodone
Pregabalin
TCAs2
Tramadol alone or
with acetaminophen
Venlafaxine ER
Botulinum toxin*
Dextromethorphan
Gabapentin-venlafaxine*
Levodopa*
Level A Rating
for Efficacy
Recommendations as First-Line
Treatment
Duloxetine
Gabapentin
Pregabalin
TCAs
Venlafaxine ER
Recommendations as
Second- or
Third-Line
Treatment
Opioids
Tramadol3
Gabapentin
Capsaicin
Pregabalin
Opioids
TCAs
Lidocaine plasters4
Capsaicin cream
Valproate*
Benzydamine (topical)
Dextromethorphan
Fluphenazine
Memantine
Lorazepam
Mexiletine
Tramadol
Lamotrigine (CPSP)
TCAs (SCI, CPSP)
Tramadol (SCI)*
Opioids
Gabapentin
Carbamazepine
Pregabalin
Gabapentin
TCAs
Duloxetine (found effective in allodynia in one
study)
Lamotrigine in SCI (except
in patients with allodynia
in one study)
Levetiracetam
Mexiletine
S-ketamine iont.
Valproate
Cannabinoids
(MS)
Lamotrigine
Opioids
Tramadol
(SCI)
33
BTX-A
579
TCAs
243
Opioids
39
Lidocaine patch
797
SNRIs
2738
Tramadol
333
Gabapentin/pregabalin
389
Capsaicin
SSRIs
122
431
NGX capsaicin
214
Cannabinoids
10
12
ns
NNT
Fig. 1. Combined number-needed-to-treat (NNT) values for various drug classes in all central and peripheral
neuropathic pain conditions (not including trigeminal neuralgia, cancer-related neuropathic pain, or radiculopathies).The circle sizes indicate the relative number (given in parentheses) of patients who received active
treatment drugs in trials for which dichotomous data were available. It is important to note that because studies
on tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids are mainly
crossover trials and studies on SNRIs and gabapentin or pregabalin are mainly parallel-group design studies,
a direct comparison of NNT values across drug classes cannot be made. Adapted from Finnerup et al.8 Abbreviations: BTX-A = botulinum toxin A; ns = absolute risk difference not significant; SNRIs = mixed serotoninnorepinephrine reuptake inhibitors.
(probably due to severe pain in some patients). The drug did not
impair sensory function, as tested with a standard sensory evaluation, in PHN and HIV neuropathy after repeated applications
for up to 1 year,47 but no in-depth assessment was performed.
In human volunteers, only a transient impairment of density of
epidermal fibers (lasting 1 week) has been evidenced on skin
punch biopsies after a single application, but there was a 93%
recovery rate after 6 months.48 However, it is not clear whether
these data are applicable to patients with peripheral nerve lesions after repeated applications. The capsaicin patch may be
applied for 30 or 60 minutes to the painful area, limited to a
maximum area of 1,000 cm2.
Is It Possible to Improve
Therapeutic Outcome?
Despite newer drugs and the rationale for combination therapy
that may improve the therapeutic response, the response to most
treatments of neuropathic pain is generally modest, with a number needed to treat for 50% pain relief (the number of patients
Botulinum Toxin A
Despite newer drugs and the rationale for
combination therapy that may improve
the therapeutic response, the response
to most treatments of neuropathic pain
is generally modest
Cannabinoids
The therapeutic potential of cannabinoids has extensively
investigated in chronic pain following the discovery of cannabinoid receptors and their endogenous ligands. Oromucosal
cannabinoids (2.7 mg delta-9-tetrahydrocannabinol/2.5 mg
cannabidiol) have been found effective in multiple sclerosisassociated pain and in refractory peripheral neuropathic pain
associated with allodynia (refs. in Attal et al.7). Adverse events
include dizziness, dry mouth, sedation, fatigue, gastrointestinal
effects, and oral discomfort.7 Although no impairment of cognition or psychoactive effects was found in neuropathic pain, it is
well known that cannabis may exacerbate mental conditions.54
6
Conclusion
14. Wiffen P, McQuay H, Edwards J, Moore RA Gabapentin for acute and chronic
pain. Cochrane Database Syst Rev 2009;20:CD005452.
All recommendations for the pharmacological treatment of neuropathic pain now propose antiepileptics (gabapentin or pregabalin), TCA or SNRI antidepressants, or topical lidocaine as the first
line of treatment for neuropathic pain in general or for
18. Eisenberg E, McNicol ED, Carr DB. Efficacy and safety of opioid agonists in the
treatment of neuropathic pain of nonmalignant origin: systematic review and
meta-analysis of randomized controlled trials. JAMA 2005;293:304352.
19. Benedetti F, Vighetti S, Amanzio M, Casadio C, Oliaro A, Bergamasco B, Maggi
G. Dose-response relationship of opioids in nociceptive and neuropathic postoperative pain. Pain 1998;74:20511.
20. Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic nonmalignant pain: systematic review of randomised trials of oral opioids. Arthritis
Res Ther 2005;7:R104651.
21. Portenoy RK, Farrar JT, Backonja MM, Cleeland CS, Yang K, Friedman M,
Colucci SV, Richards P. Long-term use of controlled-release oxycodone for noncancer pain: results of a 3-year registry study. Clin J Pain 2007;23:28799.
22. Upadhyay J, Maleki N, Potter J, Elman I, Rudrauf D, Knudsen J, Wallin D,
Pendse G, McDonald L, Griffin M, Anderson J, Nutile L, Renshaw P, Weiss R,
Becerra L, Borsook D. Alterations in brain structure and functional connectivity in
prescription opioid-dependent patients. Brain 2010;133:2098114.
23. Crofford LJ. Adverse effects of chronic opioid therapy for chronic musculoskeletal
pain. Nat Rev Rheumatol 2010;6:1917.
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finnerup@ki.au.dk
Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have
not involved any verification of the findings, conclusions, and opinions by IASP. Thus, opinions expressed in Pain: Clinical Updates do not
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