Lecture 4.6 - Pain management (Neuropathic Pain) Flashcards
Neuropathic pain characterized by….
burning, tingling, shooting or electric quality
Treatment options for Neuropathic pain
TCA
Duloxetine
Pregabalin + Gabapentin
Topical Lidocaine + Capsaicin
Opioid agents: Tramadol, Tapentadol, Methadone, Oxygen ER, morphine
Cannabinoids
Algorithm for Neuropathic pain
Try 1st line agents (Pregabalin, Gabapentin, Duloxetine, Venlafaxine, Nortriptyline, Desipramine) or topical lido/capsaicin
If no clinically meaningful effect then….
- Switch to another one of those
- Try combining
C. Add tramadol if first options don’t work
If no clinically meaningful effect or not tolerated then….
- Refer to pain clinic
Pregabalin info
Similar efficacy to gabapentin
can be use in combo with lido, capsaicin, TCA, SNRI
SE: CNS, Dizziness, Nausea, edema, weight gain..caution elderly
Pregabalin FDA approved indications
Diabetic peripheral neuropathy
Postherpetic neuralgia
Fibromyalgia
Pregabalin dosing
Can be habit forming
Req titration, Dosed BID/TID
adjust in renal insufficiency, taper is D/C
Gabapentin FDA approved indications
Post herpetic neuralgia
ER approved for Restless leg syndrome
Gabapentin info
can be use in combo with lido, capsaicin, TCA, SNRI
similar efficacy as pregabalin + TCA
Gabapentin Dosing + SE
titrate dose
Adjust for renal issues
SE: similar to pregabalin
DI w/ other drugs with CNS effects + acid suppressive
Duloxetine FDA approved indications
DM neuropathy
Fibromyalgia
Lower back pain/ Osteoarthritis but not super effective
Duloxetine SE
SE: Nausea, dizziness, somnolence, fatigue…take on full stomach
Don’t open capsule, taper when DC
Don’t combo w/ other antidepressants, can use w/ anticonvulsants or topicals**
DI w/ tramadol + other drugs
Dose: 60mg (30mg QD for 1 week then inc)
Venlafaxine SE
Can inc BP if have high BP, need to monitor
Nausea, somnolence, HA, insomnia, cardiac rhythm change
TCA FDA approvals
none for pain but useful in pain
TCA Dosing counseling
use lowest dose to start at night to minimize SE
Take 10-12hrs before away time, sedation starts 1-3hrs…helps avoid being groggy
TCA can be used in combo with….
Anticonvulsants or topicals
TCA SE
Sedation
Anticholinergic ( Dry mouth, constipation, urnary retention, blurred vision, tachycardia)
Careful in elderly ppl, BPH**
SSRI info
inferior to TCAs but better SE profile
Partially effective for DM neuropathy
Fluoxetine generally not effective
Fibromyalgia is…
A disorder of chronic, widespread pain and tenderness
associated with poor sleep, fatigue and depression
Approaches used for Fibromyalgia
Multi modal therapeutic approaches of non-pharm and pharmacologic approaches
Drugs used for Fibromyalgia
Non-opioids/Weak + Opioids
Cannabinoids
Muscle relaxants
Antidepressants
Antiepileptic like gabapentinoids
OTC agents
Physical modalities - PT, Massage, chiropractic, acupuncture
FDA approved agents Fibromyalgia
Duloxetine (Cymbalta)**
Pregabalin (Lyrica)***
Milnacipran (Savella)
Non-FDA approved agents Fibromyalgia
Gabapentin
Tramadol
TCA
Cyclobenzaprine
Agents to avoid for Fibromyalgia
NSAIDs
Capsaicin
Opioids
Malignant vs non-maligant
Malignant = cancer related
non-malignant = non-cancer
Bone pain due to…
cancer metastases
due to tumor growing on bone
“sore, aching”
Bone pain treatment
NSAIDs = block prostaglandins being released due to bone breaking,
Radiation = reduces tumors
Opioids = alter pain perception
Bisphosphate therapy due to tumor causing imbalance caused..usually IV
Goal of cancer pain treatment
- provide enough pain relief to tolerate diagnostic
- Permit optimal function
- pt be comfortable
