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Pain > Neuromyalgia and Fibromyalgia > Flashcards

Neuromyalgia and Fibromyalgia Flashcards

1
Q

What are the two types of neuropathic pain?

A

Lesion

Disease

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2
Q

What is a lesion?

A

Direct damage

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3
Q

What is disease neuropathic pain?

A

Indirect damage

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4
Q

What is the pathophysiology of neuropathic pain?

A

Neuropathic injury stimulates sensitization and induces long-term abnormal neural activity along afferent pathways
Spinal cord dorsal horn neurons show excitatory responses and decreases in firing threshold
Persistent molecular changes result in potentiated changes in the peripheral, spinal, and cortical levels

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5
Q

When is neurologic pain typically the worst?

A

At night

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6
Q

What are the 3 types of neuropathic pain?

A

Diabetic neuroapthy
Post-herpetic neuralgia
Trigeminal neuralgia

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7
Q

What is the presentation of diabetic neuropathy?

A

Diffuse and symmetric length-dependent injury to peripheral nerves

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8
Q

How is diabetic neuropathy diagnosed?

A

Diabetes

Monofilament/tuning fork test

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9
Q

What is the presentation of post-herpetic neuralgia?

A

Burning, aching, electric shock like pain or itching associated with the outbreak of a HZV rash that continues after the resolution of the infection

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10
Q

How does age correlate to post-herpetic neuralgia?

A

The older the patient is at shingles onset, the more likely they are to have post-herpetic neuralgia

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11
Q

What can be administered w/in 72 hours of a shingles outbreak to prevent post-herpetic neuralgia?

A

Antiviral agents

Amitriptyline

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12
Q

What is the diagnosis of post-herpetic neuraliga?

A

Burning pain that continues for 90 days after resolution of a herpes zoster rash

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13
Q

What is the presentation of trigeminal neuralgia?

A

Pain that is sudden, unilateral, severe, brief, stabbing and recurrent episodes in one or more branches of the trigeminal nerve

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14
Q

How is trigeminal neuralgia diagnosed?

A

CT scan that shows:
Compression of the 5th cranial nerve
Structural abnormality of the 5th cranial nerve

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15
Q

How is fibromyalgia characterized?

A

Widespread musculoskeletal pain and tenderness

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16
Q

What are the neuropsychological sx of fibromyalgia?

A 
Fatigue
Nonrestorative sleep
Cognitive dysfunction
Anxiety
Depression
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17
Q

What are common comorbidities of fibromyalgia?

A

Chronic HA
IBS
Pelvic pain syndromes

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18
Q

Are men or women more likely to have fibromyalgia?

A

Women x9

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19
Q

What is the pathophysiology of fibromyalgia?

A

Can be triggered by infection, metabolic/psychiatric comorbidities
Polymorphisms in the serotonin transporter gene and the enzyme that inactivates catecholamines

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20
Q

What is the diagnosis of fibromyalgia?

A 
"Pain all over"
Typically above and below the waist on both sides of the body
Poorly localized
Difficult to ignore
Severe in intensity
Present most of the day on most days for 3+ months
Fatigue, stiffness
Routine labs are normal
Diagnosis of exclusion
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21
Q

What is the nonpharm treatment for neuropathic pain and fibromyalgia?

A 
Education
Physical conditioning
Relaxation exercise
Sleep hygiene
Management of comorbidities
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22
Q

What is the nonpharm treatment that is specific for neuropathic pain?

A

TENS

Ablation of nerve bundle (LAST LINE)

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23
Q

What are the anticonvulsants used in neuropathic pain and fibromyalgia?

A

Pregabalin
Gabapentin
CBZ
Lamictal

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24
Q

What agents must be adjusted in renal impairment?

A

Pregabalin
Gabapentin
SSRIs
TCAs

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25
Q

What is the MOA of pregabalin?

A

Binds to Ca channels and modulates excitatory neurotransmitters which affects nociception

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26
Q

How does pregabalin relate to gabapentin?

A

Pregabalin is a prodrug with a higher affinity

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27
Q

What is the only drug that is FDA apparoved for diabetic neuropathy?

A

Pregabalin

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28
Q

What are the AEs of pregabalin and gabapentin?

A

Dizziness
Drowsiness
(Gabapentin much worse)

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29
Q

What is the MOA of gabapentin?

A

Structurally related to GABA, binds throughout the brain and may modulate the release of excitatory neurotransmitters which affect nociception

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30
Q

What is the MOA of CBZ in neuropathic pain and fibromyalgia?

A

Unknown

Modulates neurotransmitter activity at neuronal synapses and Na channels to decrease peripheral nerve excitability

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31
Q

What is CBZ chemically related to?

A

TCAs

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32
Q

What are DDIs of CBZ?

A

3A4 inducers

CNS depressants

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33
Q

What is FDA approved for trigeminal neuralgia?

A

CBZ

34
Q

What is the MOA of lamictal?

A

Inhibits the release of glutamate and stabilizes the nueronal membranes by inhibiting sodium channels

35
Q

What are the AEs of CBZ?

A

Somnolence
Dizziness
Gait disturbance

36
Q

What are the AEs of lamictal?

A

Nausea
Edema
Dizziness

37
Q

What are the DDIs of lamictal?

A

VPA (SJS)

CNS depressants

38
Q

What can lamictal be used for?

A

Trigeminal pain

Neuropathy related to HIV pain

39
Q

What are the MOA of TCAs?

A

Modulate neurotransmitter activity at neuronal synapse at descending inhibitory spinal pathways

40
Q

How does Amitripyline and imipramine work?

A

Inhibit presynaptic reuptake of NE and serotonin

41
Q

How does despiramine work?

A

Inhibits presynpatic reuptake of NE

42
Q

Does mood elevating properties of TCAs affect pain relief?

A

No, indeoendent

43
Q

What are AEs of TCAs?

A 
Dry mouth
Constipation
Orthostaic hypotension
Sedation
QTc prolongation
44
Q

When should TCAs be given?

A

At bedtime

45
Q

What is the MOA of SSRIs?

A

Decrease serotonin reuptake at the neuronal synapse at descending inhibitory spinal pathways

46
Q

What are AEs of SSRIs?

A 
Somnolence
Dizziness
Nausea
Sexual dysfunction
Sweating
WEakness
47
Q

What is the MOA of SNRIs?

A

Inhibits serotonin and NE reuptake at the neuronal synapse at descending inhibitory pathways in the CNS

48
Q

Are SNRIs or SSRIs more effective for neuropathic pain?

A

SNRIs

49
Q

What are AEs of SNRIs?

A 
GI distress
HA
Somnolence
Fatigue
Nausea
Increased bleeding risk
CNS depression
HYPERGLYCEMIA
50
Q

What is the MOA of capsaicin?

A

Works on the vanilloid 1 receptor (TRPV1) to cause local damage and defunctionalize pain sensory receptors’ ability to send pain signals
Desensitizes sensory axons and inhibition of pain transmission initiation
Repeated application depletes the neuron of substance P and prevents re-accumulation

51
Q

How is the capsaicin patch applied?

A

Applied in physicians office for 60 minutes

52
Q

How many patches of capsaicin can be applied at one time?

A

4 patches

53
Q

How often can capsaicin treatment be repeated?

A

Every 3 months

54
Q

How do we pretreat for capsaicin patches?

A

Lidocaine

55
Q

What are AEs of capsaicin?

A

Short term increases in BP and HR

Local erythema and pain

56
Q

What is the MOA of topical lidocaine?

A

Interrupts peripheral nerve impulses

57
Q

How many patches of lidocaine can be applied at the same time?

A

3

58
Q

Which opioid has modest efficacy for fibromyalgia and neuropathy?

A

Tramadol

59
Q

Which opioid can be used last line in diabetic neuropathy?

A

Oxycodone ER

60
Q

What can cyclobenzaprine be used for?

A

Fibromyalgia

61
Q

How does botulinum toxin work in pain?

A

Serotype A inhibits the secretion of substance P and calcitonin

62
Q

How does alpha-lipoic acid work?

A

Antioxidant effect that causes improved nerve blood flow

63
Q

When would alpha-lipoic acid be administered?

A

For use at the beginning to slow progression

64
Q

What is benfotiamine?

A

Fat soluble vitamin B1

65
Q

What are first line agents for diabetic neuropathy?

A

Pregabalin
SNRIs
TCAs
Gabapentin

66
Q

What are the second line agents for diabetic neuropathy?

A

CBZ
Tramadol
Capsaicin
Lidocaine

67
Q

What are third line agents for diabetic neuropathy?

A

Oxycodone ER

68
Q

What should not be used in diabetic neuropathy?

A

Cyclobenzaprine

Opioids

69
Q

What are first line agents for post-herpetic neuralgia?

A 
Gabapentin
Pregabalin
Lidocaine patch
TCAs
Tramadol
70
Q

What is the second line agents for post-herpetic neuralgia?

A

Capsaicin

71
Q

What are first line agents for trigeminal neuralgia?

A

Duloxetine
TCAs
CBZ
OxCBZ

72
Q

What are second line agents for trigeminal neuralgia?

A

Lamictal

73
Q

How do we treat fibromyalgia?

A

Treatment is symptom specific

74
Q

If the patient has fibromyalgia and difficulty sleeping, what medications should be given?

A

Amitriptyline

Cyclobenzaprine

75
Q

If the patient has fibromyalgia and depression/anxiety, what medication should be given?

A

Duloxetine

76
Q

What are second line agents for fibromyalgia?

A

Anticonvulsants

77
Q

What medications should be avoided in fibromyalgia?

A

Opioids and NSAIDs

78
Q

What is the treatment for acute/subacute lower back pain?

A

Non-pharm treatment (heat, massage, acupuncture, spinal manipulation)
If pharm treatment is desired, NSAIDs and skeletal muscle relaxants are preferred

79
Q

What is the initial treatment for chronic lower back pain?

A

Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation

80
Q

If the initial treatment of chronic lower back pain is inadequate, what are the other treatments?

A

NSAIDs 1st line
Tramadol and duloxetine 2nd line
Opioids after failure of others and consideration of potential risk

Pain (5 decks)

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