EFNS - Dor neuropática

Question 1

Como fazer o manejo da dor neuropática das polineuropatias?

Answer 1

We recommend TCA, gabapentin, pregabalin and SNRI (duloxetine, venlafaxine) as firstline treatment in PPN (notably related to diabetes) (levelA).Tramadol(levelA)is recommended secondline except for patients with exacerbations of pain (for the tramadol/acetaminophen combination) or those with predominant coexisting non-neuropathic pain (in view of its largely established efficacy in nociceptive pain). Third-line therapy includes strong opioids because of concerns regarding their long-term safety including addiction potential and misuse, which warrants further RCTs [4,48]. In HIV-associated polyneuropathy, only lamotrigine (in patients receiving antiretroviral treatment) (level B), smoking cannabis (level A) and capsaicin patches (level A) were found moderately useful.

Question 2

Qual o tratamento da neuropatia pós-herpética?

Answer 2

We recommend TCA or gabapentin/pregabalin as firstline treatment in PHN (level A). Topical lidocaine (level A, less consistent results) with its excellent tolerability may be considered first line in the elderly, especially if there are concerns regarding the CNS side effects of oral medications. In such cases, a trial of 2–4 weeks before starting other therapy is justified [54]. Strong opioids (level A) and capsaicin cream are recommended as second choice (see section 1). Capsaicin patches are promising (level A), but the long-term effects of repeated applications particularly on sensation are not clarified.

Question 3

Qual o tratamento para a neuralgia do trigêmeo?

Answer 3

In agreement with previous guidelines [7,61,62], carbamazepine (level A) and oxcarbazepine (level B) are confirmed first line for classical TN. Oxcarbazepine may be preferred because of decreased potential for drug interactions. Patients with intolerable side effects may be prescribed lamotrigine (level C) but should also be considered for a surgical intervention. We deplore the persistent lack of RCTs in symptomatic TN.

Question 4

Qual o tratamento da dor neuropática central?

Answer 4

We recommend pregabalin (level A), amitriptyline (level B, level A in other NP conditions) or gabapentin (level A in other NP conditions) as first line in CP (Table 1). Tramadol (level B) may be considered second line. Strong opioids (level B) are recommended second or third line if chronic treatment is not an issue. Lamotrigine may be considered in CPSP or SCI pain with incomplete cord lesion and brush-induced allodynia (level B) and cannabinoids in MS (level A) only if all other treatments fail.