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Therapeutics P3 Fall > Neuropathic Pain > Flashcards

Neuropathic Pain Flashcards

1
Q

Neuropathic pain

A

Pain caused by a lesion or a disease of the somatosensory nervous system.

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2
Q

Spontaneous transmission (continuous)

A

Burning, throbbing, aching, shooting

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3
Q

Spontaneous transmission (intermittent)

A

shooting, stabbing, electric shock-like

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4
Q

Hyperalgesia

A

Increased pain from a stimulus that usually causes pain

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5
Q

Allodynia

A

Pain due to a stimulus that usually does not cause pain

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6
Q

Does treatment for neuropathic pain bring instant relief?

A

No. Treatment may take weeks to show results. “Don’t expect this to act like an as needed pain med for a headache”

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7
Q

TCAs for Neuropathic Pain

A

Secondary: nortriptyline, desipramine
Tertiary: Amitriptyline***, imipramine

Adv:
- most data
- once daily dosing
- concomitant insomnia/depression

D-Adv:
- delayed onset
- Anti-ach, cardiotoxic

Dosing: 25mg QHS
(Trial at least 6-8 weeks, 2 weeks @ max to state failure)

***Most studied

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8
Q

TCA MOA in neuropathic pain

A

block serotonin & NE reuptake

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9
Q

SNRIs in neuropathic pain

A

Duloxetine & Venlafaxine

+
- duloxetine FDA approved in PDN, fibromyalgia
- concomitant depression
- ADE profile

–
- risk of serotonin syndrome
- duloxetine CI with hepatic impairment and ESRD (CrCl < 30)

Dosing:
D: 30mg QD (max 60mg BID)
V: 37.5 mg QD-BID (max 225 mg/day)

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10
Q

Milnacipran (Savella)

A

SNRI, 3:1 NE:5HT, NMDA receptor binding, lacks histaminic and muscarinic activity

+
- FDA approved for fibromyalgia
- well tolerated
- may improve fatigue

–
- BID dosing
- HTN

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11
Q

a-2 delta ligands (pregabalin, gabapentin) MOA

A

bind to voltage gated calcium channels -> less calcium entering presynaptic terminal -> slows excessive release of excitatory neurons

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12
Q

Gabapentin

A

Advantages:
- few DIs and ADRs
- FDA approved for PHN

Disadvantages:
- mild CNS depression, significant toxicity
- complicated dose adjustment in renal disease

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13
Q

Gabapentin Renal Dose Adjustment

A

CrCl….
>/=60 -> no adjustment
30-59 -> 400-1400mg/day in BID dosing
>15-29 -> 200-700 QD
15 -> 100-300 mg/day QD
<15 -> decrease daily dose in proportion to CrCl

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14
Q

Pregabalin

A

Advantages:
- Few DIs and ADEs
- concomitant anxiety
- FDA indicated for PDN, PHN, and fibromyalgia

Disadvantages:
- DEA schedule 5 (euphoria and dependence)
- mild CNS depression, significant in toxicity
- renal insufficiency

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15
Q

Tramodol

A

Advantages:
- weak pain
- less respiratory depression
- low abuse potential
- neuropathic pain (inhibits 5HT and NE reuptake)

Disadvantages:
- drug interactions (carbamazepine, quinidine, TCA, SSRIs)

ADE:
- dizziness
- GI, constipation
- seizures

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16
Q

Tapentadol (Nucynta)

A

indication: neuropathic pain associated with PDN

  • mu agonist
    -blocks NE reuptake
  • DEA schedule 2
  • dosing every 4-6 hours
17
Q

Capsaicin

A

MOA: depletes and prevents re-accumulation of substance-P in peripheral sensory neurons

Formulations:
- Qutenza 8% topical patch (pre-treat with local anesthetic)
- 0.025% patch
- topical cream (zostrix)

  • application issues
18
Q

Lidocaine

A

Indication: PHN, topical anesthesia

Onset: 5-10 minutes
How supplied:
- Rx (patch 5%, viscous soln 2%)
- OTC (up to 4%)

19
Q

Painful Diabetic Neuropathy (Pathophysiology)

A
  • Damage to peripheral nerves (hyperexcitability + spontaneous impulses)
  • abnormal electrical connections
  • coupling of sympathetic and afferent neurons and abnormal release of substance P from A fibers
  • persistent nerve stimulation activates NDMA receptors
20
Q

PDN treatment

A
  • inc NE and 5HT in synaptic cleft
  • TCAs
  • SNRIs (duloxetine & venlafaxine)
  • a-2 delta ligands (Gabapentin & pregabalin)
21
Q

Post-herpetic Neuralgia (Patho)

A
  • reactivation of Varicella-Zoster virus
  • distribution along dermatomes
  • often causes PHN d/t sensory nerve damage -> reduced neurite densities
22
Q

PHN treatment

A

TCAs

Antiepileptics
- Gabapentin:
– Gralise ER tab - titrate to 1800 mg daily
– Horizant (Gabapentin Enacarbil ER) 600mg tab BID
- Pregabalin
- Divalproex Na

Tramadol

Opioids (OxyContin)

Lidocaine (FDA approved)

Capsaicin

23
Q

Fibromyalgia (Patho)

A

Enhanced sensitivity to stimuli (heat and cold)
Dull ache in all 4 quadrants of the body
Often accompanied with fatigue and sleep disturbances
- fibromyalgia fog

24
Q

Fibromyalgia treatment

A

FDA approved: Duloxetine, milnacipran, pregabalin

Recommended: Amitriptyline, tramadol, cyclobenzaprine

Non-pharm: aerobic and strengthening exercise, CBT, yoga/mindfulness

Therapeutics P3 Fall (21 decks)

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