PHARMACOLOGICAL TREATMENT OF NEUROPATHIC PAIN 神经病理性疼痛的药物治疗.ppt

Management of Neuropathic Pain Mellar P Davis MASCC ,June 2009 Pharmacological treatment of neurologic pain relies on evidence from large randomized controlled trials Attal 2006 Dworkin 2007 Despite advances in research and clinical trials, a considerable number of individuals do not get relief NNT- 3-5 for most drugs Response is defined as a “30-50% reduction in pain severity empiric drug trials – “trial and error” choices based on mechanism gulf between empiricism and mechanistic drug choices Baron 2006 Woolf 1998 It is unclear which laboratory pain responses are most strongly associated with the experience of pain in daily life Edwards 2003 Tools for Neuropathic Pain Neuropathic pain questionnaire, Leeds assessment of neuropathic signs and symptoms Neuropathic Pain Symptom Inventory Definite NP, possible NP, unlikely NP Definite NP had greater pain intensity Definite NP had greater opioid escalation index Differences Between Peripheral and Central Neuropathic Pain Less evidence for central pain syndromes Differences in drug classes (cannabinoids) Central pain syndromes do not respond to peripheral blocks or ablative procedures Motor cortex stimulation Pain Relief 30-50% pain relief may not correlate with Patient Global Impression of change (PGIC) Analgesia vs. function Differential response on the several pain mechanisms found in a single individual Allodynia Burning C fiber pain Spontaneous pain Pain Relief Not “all or none” but continuous Balance of pain relief, medication burden, side effects, QOL, function Artifact to use binomial outcomes Dosage Tolerable dose vs therapeutic dose (serum levels vs empiric recommendations) Combinations may reduce the tolerable dose Duration Maximum tolerable dose and duration of time to see maximum benefit Pharmacodynamic optimal time for response is largely unknown Maintenance period of 3 weeks, longer if suggested by RCTs Drug specific Poorly relat