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Neuro Exam 1 > Neuropathic pain > Flashcards

Neuropathic pain Flashcards

1
Q

CASE 1 - PK, a 58-year-old Native American male, came
to the UNM Pain Clinic today for his pain
assessment. He was referred by his primary care physician. He has a 20-year history of diabetes.
 How would you assess his pain? . . . what are the steps

A
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2
Q

Case 1 (continued)
 How would you assess pain?
 Step 1: We need to know. . . .about pain . . . about etiology of pain

A 
1.) About pain
 Quality and quantity of pain (description, pain scale, etc.)
 Location 
 Previous treatment response – what medications has patient tried, effective or not effective. Why? 
 What makes pain better/worse
.
2.) About etiology of pain
 Cause of pain
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3
Q

Case 1 (continued)
 How would you assess pain?
 Step 1: We need to know. . . .about daily activity. . . diagnosis and treatment plan

A 
1.) About daily activities
 Duration of concomitant disease(s), disease states, psychiatric issues, etc.
.
2.) About diagnosis and treatment plan
 Accurate diagnosis
 Selection of appropriate medications
 Guideline and patient-specific factors
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4
Q

Case 1 (continued)
 How would you assess pain?
 Step 1: We need to know. . .. About medical history and comorbidities. . . About diagnosis and treatment plan

A

1.) About medical history and comorbidities
 Duration of concomitant disease(s), disease states, mental status, etc.
 Important information for selection of treatment agent
.
2.) About diagnosis and treatment plan
 Accurate diagnosis
 Imaging, physical exam (e.g., neuro, muscle-skeletal exam)
 Current treatment plan, including medications
 Guideline and patient-specific factors

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5
Q

Case 1 (continued)
 How would you assess pain?
 Step 1a: Pain assessment. . . Assess quality and quantity (general)

A
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6
Q

Step 1a: Pain assessment
- Assess quality and quantity
OPQRST . . . Provocation or Palliation

A

 Medication(s)/treatment(s) tried
 Effective or not effective?
 If not effective, ask reasons (e.g., adverse reactions)

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7
Q

Step 1a: Pain assessment
- Assess quality and quantity
OPQRST . . . Quantity of pain

A
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8
Q

Step 1a: Pain assessment . . .Pain scale?

A
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9
Q

Step 1a: Pain assessment. . . Comorbidities

A
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10
Q

Step 1a: Pain assessment

 Other considerations: nonverbal communication

A
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11
Q

Step 1b: Establishment of treatment

A
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12
Q

Types of pain (review) part 1

Acute pain vs. chronic pain

A

 Acute pain: requires temporal pain management

 Chronic pain: pain continues beyond the expected time of tissue healing; requires long-term pain management

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13
Q

Types of pain (review) part 2

Nociceptive pain vs. non-nociceptive pain

A 
1.) Nociceptive pain
 Somatic pain
 Visceral pain
 Inflammatory pain 
.
2.) Non-nociceptive pain
 Neuropathic pain
 Functional pain
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14
Q

Types of pain (review). . . Nociceptive pain

A

Peripheral stimuli (temperature change, mechanical stimuli or chemical stimuli)

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15
Q

Types of pain (review). . . Inflammatory pain

A

Tissue damage or inflammatory reactions

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16
Q

Types of pain (review). . . Neuropathic pain

A

Central and peripheral nerve damage

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17
Q

Types of pain (review). . . Functional pain

A

Normal nerve function but abnormal nerve conduction

18
Q

Types of neuropathic pain. . . 2 types

A

• Central neuropathic pain syndrome - Nerve damage on central nervous system
(brain/spinal cord)
• Peripheral neuropathic pain syndrome- Nerve damage on peripheral nervous system

19
Q

General treatment plans for neuropathic pain

A
  • Treatment for the disease/condition that triggers or exacerbates neuropathic pain… e.g., diabetes
  • Treatment for neuropathic pain. . . Pharmacotherapy/nonpharmacotherapy and Follow guideline and consider patients’ specific factors
20
Q

Treatment plan

• Treatment goals. . . Should be realistic!!!

A

• Medications are useful, but have finite benefits
• Realistic goals: e.g., walking with a granddaughter for 30
minutes every day, sleep at least 6 hours without pain, pain
scale of 3/10
• Unrealistic goal: e.g., pain free after initiation of medication
• There are multiple etiologies for neuropathic pain
• Multiple medications may need to be utilized

21
Q

Tips of pharmacotherapy for neuropathic pain

A
  • Ideal analgesia = pain control + functional status
    .
  • PK/PD and clinical factors to select appropriate pain medicine!… Pharmacokinetics: how a drug works in the body
     ADME
     Drug formulation: IR vs. ER
     Administration routes: PO vs. parenteral (PO: preferable.. Other routes: PR, IV, IM, transdermal)
     Distribution (Blood brain barrier)
     Metabolism (Hepatic function, Metabolites: e.g., nortriptyline from amitriptyline)
     Excretion/elimination (Renal function)
    Pharmacodynamics: how the body reacts to a drug –> Onset of action, Peak effect, Duration of action
22
Q

The pain pathway . . .

A
23
Q

Pharmacotherapy – overview . . .ascending pathway and descending pathways

A
24
Q

Treatment algorism for neuropathic pain

A
25
Q 
Step 2: Initiation of therapy 
 Treatment for neuropathic pain
Pharmacotherapy – start slow, go slow...
 First-line agents (strong recommendations, equally 
effective):
A
26
Q

Step 2: Initiation of therapy

 Treatment for neuropathic pain . . .Gabapentin, pregabalin

A

 Block nerve impulse by binding Ca channels
↓Ca++ influx into presynaptic nerves
↓ release of excitatory neurotransmitters
↓ pain nerve firing
 ADRs
 Sedation, peripheral edema

27
Q

Mech, dose, side effects, PEARLS of Gabapentin, pregabalin

A
28
Q

Step 2: Initiation of therapy

 Treatment for neuropathic pain. . . SNRIs

A

 Block reuptake of NE and 5HT
 Well-tolerated
 Safer than TCAs (cardiotoxicity)
 ADRs–> Sedation, GI ADRs (e.g., nausea), Insomnia, Headaches

29
Q

mech, dose, side effects, PEARLS of SNRIs . . . Venlafaxine (Effexor®), Duloxetine
(Cymbalta®), Milnacipran (Savella®)

A
30
Q

Step 2: Initiation of therapy. . .Treatment for neuropathic pain . . . TCAs

A

 Effective to treat continuous burning pain
 Block voltage-gated Na channels
 Antagonize NMDA receptors
 Block alpha adrenergic receptor
 ADRs: Anticholinergic effects, Sedation, Orthostatic hypotension, Weight gain, Cardiotoxicity

31
Q

mech, dose, side effects, PEARLS of TCAs . . . Amitriptyline, Nortriptyline, Desipramine

A
32
Q

Step 2: Initiation of therapy
 Treatment for neuropathic pain
 Pharmacotherapy – start slow, go slow
 Second-line agents (weak recommendations): . . .

A

Acute condition, exacerbation, neuropathic cancer pain, first-line agents/other pharmacotherapy options are not effective
 Capsaicin topical
 Lidocaine topical
 Tramadol 200-400 mg/day

33
Q

Step 2: Initiation of therapy
 Treatment for neuropathic pain
 Pharmacotherapy
 Other agents (weak/inconclusive recommendations): . .

A

 Antidepressants: SSRIs
 Anticonvulsants (membrane stabilizers): carbamazepine, oxcarbazepine, lacosamide, lamotrigine, topiramate, valproic acid, zonisamide, etc.
 Ketamine
 Botulinum toxin A 50-200 units to the painful area every three months, specialist use
 Opioids individual titration (Only when none worked)

34
Q

Step 2: Initiation of therapy
 Treatment for neuropathic pain
 Pharmacotherapy
 Other agents (weak/inconclusive recommendations):
Peripheral nerve injury results in abnormal accumulation of
Na+ channels within neuron. . . what can you use for it?

A

Membrane stabilizers: carbamazepine, oxcarbazepine, lamotrigine, topiramate, valproic acid, etc.
 Decreases presynaptic nerve cell depolarization by blocking Na+ channels
 Decreases neuronal firing in the thalamus

35
Q

mech, dose, side effects, PEARLS of Membrane stabilizers: carbamazepine, oxcarbazepine, topiramate, valproic acid

A
36
Q

Step 2: Initiation of therapy

 Treatment for neuropathic pain. . . Nonpharmacotherapy

A
37
Q

Step 3: Reassessment of pain, treatment, and functional goals part 1

reassessment of pain and therapy (Pharmacotherapy/nonpharmacotherapy for neuropathic pain)

A 
1.) Pain
 Quality and quantity of pain 
 Reset treatment goals
2.) Therapy
 Pharmacotherapy/nonpharmacotherapy for neuropathic pain
 Effective vs. not effective
 Dose adjustment
 Trial of different first-line agent(s)
38
Q

Step 3: Reassessment of pain, treatment, and functional goals part 2
Reassessment of Therapy . . .Pharmacotherapy/nonpharmacotherapy for concomitant disease states

A

 Obese patient – avoid valproic acid (weight gain), may be beneficial from topiramate (weight loss)
 Patients with epilepsy – may be beneficial to use antiepileptic drugs, avoid bupropion (↓ seizure threshold)
 Patients with migraine headache – topiramate may be beneficial
 Patients with anxiety – gabapentin or pregabalin may be beneficial
 Patients with depression – SNRIs may be beneficial
 Patients with sleep issue: gabapentin, pregabalin, TCAs
 Geriatric patients – avoid TCAs (Beers Criteria)

39
Q

Step 3: Reassessment of pain, treatment, and functional goals
 Best medication to use is often based on concurrent comorbidities and/or not adding to side effects of medications currently used!
 Common comorbidities includes:

A 
 Depression
 Hypothyroidism
 Hypogonadism
 ↓ Vit D
 Obesity
 Sleep Apnea
 PMH of PTSD
 PMH of sexual or physical abuse
40
Q

Step 3: Reassessment of pain, treatment, and functional goals. . . Chart!! KNOW THIS

A
41
Q

Step 3: Reassessment of pain, treatment, and functional goals
 When to determine the efficacy of medications for chronic pain?

A

 Observe patient’s condition for 4-6 weeks after initiation of medication
 Observe for an additional two weeks after achieving maximum dosage

Neuro Exam 1 (7 decks)

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