Neuropathic Pain Flashcards by Kelsey Con

what does gabapentin targget

calcium channel (central sensitization)

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what do TCAs target

NE/serotonin receptor

disinhibition

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what so SNRIs target

NE, serotonin (disinhibition)

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what does lidocaine target

sodium channels (peripheral)

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efficacy of neuropathic pain meds

not a lot of eveidednce
very few comparative trials suggest similarity
dont look at the NNT poor studies behind them
can consider them all the same and pick based on the patient

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should we use opioids

very low eficacy and lots of dependence and abuse so no

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is tramadol an exception

besides opioid receptor agonist its also inhibits NE and serotonin reuptake
lower abuse potential but still not that great

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what do we know about functioning

insufficient evidence regarding quality of life but we can assess this in our patients

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TCA side effects

constipation, dry mouth
weight gain
orthostatic hypotension
sedation

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TCA cautions

elderly, dementia, glaucoma, urinary retention, cardiac disease

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gabapentin and pregabalin SE

dizzy
sedation
peripheral edema

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gabapentin cautions

elderly
edema
fall risk
abuse potential

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SNRI SE

nausea - goes away with time
increased BP
dizziness

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SNRI cautions

hypertension

biploar

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tramadol SE

nausea
constipation
sedation
dizziness

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tramadol cautions

opioid dependence
addiction risk
seizure risk

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3 options worth a trial but just warn patient that most experience side effects

TCA
gabapentin
SNRI

non pharms

meditation 
psychosocial 
CBT 
music
exercise? - good for other stuff 
heat and ice

dosing trial for TCA

start 10-25 HS to 50-100HS

max 150

dosing trial for gabepentin

start at 300mg/day then 300-900TID

max 1200TID - max dose just see a plateau and increase in SE

dosing trial for pregabalin

start 75 BID then 150-300 BID

dosing trial for duloxetine

start 30 mg then go up to 60mg

dosing trial for venlafaine

37.5daily

then up to 150-225 daily

how long is an adequate trial of meds

once reach the low end of the usual effective dose then 2-4 weeks

onset for pain meds

1 week

ways to incease dose

fast: increase 50-100% every 3 days slow: increase 50-100% every week

why do we start low and go slow

no rush not worth risking harm to the patient side effects may result in a loss of a viable option higher doses have a low likelihood of resulting in greater benefit

drugs to use if patient has depression or anxiety

TCA - but we tend not to use doses as high as in depression | SNRI

drugs to use if patient has insomnia

gabapentin | TcA

drug to use if patient has osteoarthritis

duloxetine | tramadol

drug to use if patient has migraines

TCA

monitoring timeline

1 week to se how their doing, side effects | 2-4 weeks for efficacy: pain level and functioning

if patient sees no benefit try

increase dose if not at upper dose | it at upper dose stop and switch

if patient experiencing some benfit from med try

continue and maybe increase the dose or add another agent

if side effects not tolerable try

if there was a benefit at a lower dose decrease the dose and add another agent or stop and switch

if med tolerable and effective reassess for ongoing need in

3 months

should we use combination therapy

not a lot of evidence | may be beneficial to have ttwo diff moa?

which two do we absolutely not combine

gabapentin + opioid | NNT = NNH

lidocaine advantages

immediate onset | min systemic absorption

capsaicin recommendation

doesnt work | burning just cuases a distraction

topical option if very resistant to all treatments

ketamine

patient counseling points

benefit onset side effects cost/coverage