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An Examination of Pharmacologic Treatment
a 1st Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece b Anaesthesiology Department and Pain Relief and Palliative Care Unit, 7th IKA Hospital, Athens, Greece c Anaesthesiology Department, Creta Interclinic Hospital, Heraklion, Crete, Greece
Key Words: neuropathic pain • mechanisms • diagnosis • therapy • guidelines treatment algorithms • randomized controlled trials • meta-analysis • antiepileptic drugs • antidepressive drugs • topical antineuralgics • opioids • tramadol
Address for correspondence: Athina Vadalouca, Department of Anaesthesiology, Pain Relief and Palliative Care, Aretaieion University Hospital, Lefkon Oreon Street, Gerakas, Athens, Greece. Voice: +306936718181; fax: +302107286168. e-mail: athinajv{at}ath.forthnet.gr
Neuropathic pain is defined as pain caused by a lesion in the nervous system and is common in clinical practice. Diagnosis can be difficult. Recommendations for first-line pharmacologic treatments are based on positive results from multiple, randomized, controlled trials, and recommendations for second-line pharmacologic treatments are based on the positive result of a single, randomized, controlled trial or inconsistent results of multiple, randomized, controlled trials. The results of published trials and clinical experience provide the foundation for specific recommendations for first-line treatments, which include gabapentin, 5% lidocaine patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants (TCAs). Gabapentin (up to 3,600 mg/day) significantly reduced pain compared with placebo; improvements in sleep, mood, and quality of life were also demonstrated. Adverse effects of gababentin include somnolence and dizziness, and, less commonly, gastrointestinal symptoms and mild peripheral edema. Thus, monitoring and dosage adjustment are required, without discontinuation of the drug. Gabapentin combined with morphine achieved better analgesia at lower doses of each drug than each drug alone, with only mild adverse effects. The first medication that proved effective for neuropathic pain in placebo-controlled trials was TCAs. Treatment decisions for patients with neuropathic pain can be difficult. Interest in the mechanisms and treatment of chronic neuropathic pain has increased during the past years, resulting in significant treatment advances in the future. In this article all recent knowledge on therapeutic management of chronic neuropathic pain is presented.
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