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Treatment

Several treatment modalities are available within the field of neuropathic pain and neuropathy.

Palmitoylethanolamide, PEA: key items presented

In the following sequence of presentations we bring to you the essence of knowledge around the body-own compound and supplement palmitoylethanolamide! We start with the general introduction, an overview of palmitoylethanolamide, an endogenous cellular protectant in plants, invertebrates, vertebrates and humans, tested extensively since 1970 and widely available as food supplement. Its main action is […]

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NUCYNTA® a new opioid from Gruententhal

Combining Opioid and Nonopioid Activity in One Centrally Acting Oral Analgesic, is the communication of this newly registered opioid from the laboratories of Gruenenhal in Germany. The second wave of marketing communication is:  

  1. MU-OPIOID AGONIST, and
  2. ASCENDING PATHWAYS Works primarily on ascending pathways to inhibit transmission of pain impulses through binding to mu-opioid receptors, and
  3. NOREPINEPHRINE REUPTAKE INHIBITOR DESCENDING PATHWAYS Works primarily on descending pathways to enhance the inhibition of pain signaling through norepinephrine reuptake inhibition. 

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Treatment of neuropathic pain in elderly and frail patients

How to best treat the elderly and frail patients suffering from neuropathic pain? For painphysicians this is a key question. Happily new data are guiding our prescribing behaviour in this field. The most important issue is how to achieve optimal analgesic efficacy without creating bothersome side effects like dizziness and unsteadiness or unwanted drug interactons! For instance, the best analgesics, the TCAs in elderly can cause cognitive functiondisturbances, confusion, gait disturbances, and falls. 

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Low dose naltrexone for neuropathic pain

Low dose naltrexone is popular in the alternative treatment world. It is a bit strange, as this molecule is quite non-alternative. But low dose naltrexone (LDN) is recommended on lay internetsites for a multitude of diseases, from MS to cancer. That always provokes anti-bodies by doctors, but naltrexone indeed has anti-inflammatory properties. It might be an interesting treatment option for  treatment refractory neuropathic pain patients.

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Palmitoylethanolamide (PEA): information for MD’s

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Palmitoylethanolamide (‘PEA’) is a endogenous compound and is in Europe available for the treatment of chronic pain and chronic inflammation. Most clinical data have been gathered and published around its efficacy in various neuropathic painstates, such as in diabetes, carpal tunnel syndrome, sciatic pain, and we outline these indications and the clinical and preclinical data below. 

Under the follow link an extensive review for specialists can be downloaded. The article appeared in The Open Pain Journal (2012) 

Palmitoylethanolamide has be described as an endogenous fatty acid amide, belonging to the class of lipid signaling molecules (autocoids). Since 50 years of research around this molecule, the last decade the number of scientific papers on PEA’s biological and clinical activity has been expanded to nearly 400.

PEA has been demonstrated to bind to a receptor in the cell-nucleus (a nuclear receptor, PPAR), a number of other receptors, and therefore it exerts a great varity of biological functions related to chronic pain and inflammation. It is considered as a breakthourgh in the treament of chonic pain, and with PEA a new mechanism of action in the world of analgesics has been introduced and validated in a great number of studies.

PEA can be seen as a glia modulator and proof of principle (POP) as well as proof of concept (POC) has been generated via PEA studies of glia as an important factor in the genesis of neuropathic pain.

Brandnames of drugs containing PEA 

PEA is available under various brandnames: Normast and Pelvilen in Italy and Spain, and as PeaPure (JP Russell Science Ltd) for the rest or the world. PeaPure is available in Europe as a food supplement. 

In Normast and Pelvilen, the active ingredient is palmitoylethanolamide. In Normast and Pelvilen excipients like magnesium stearate, povidone and polisorbate are added. In the Normast sachets a sweetener has been added, sorbitol.

In PeaPure the sole content is palmitoylethanolamide (no excipients). 

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Integrated Medicine concept for the treatment of neuropathic pain

Research over the last few decades has shown an increased use of complementary and alternative therapies (CAM) and an integration of aspects of CAM into mainstream medical treatment, health care organisations and insurance plans.  It has been shown that the process of care may be as important as the outcomes of treatment, which may explain in part the relatively large popularity of CAM for many patients on a world wide base. (Muir Gray JA. Evidence-Based Healthcare. How to Make Health Policy and Management Decisions. 2. London: Churchill Livingstone; 2001) 

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Palmitoylethanolamide (PEA) versus NSAID in the treatment of TMJD pain

In a head to head comparison study the Italian research group from the Department of Orthodontics, of the  School of Dentistry, at the University of Bologna, could demonstrate that treatment with the natural analgesic compound palmitoylethalonamide (available under the brandnames Normast®  or PeaPure® ) was superior over the treatment with a classical NSAID in temporomandibular joint disorder (TMJD), or Costen syndrome.

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Pregabalin, Lyrica® not for fibromyalgia in Europe

The EMEA has adviced against the marketing authorization of Lyrica® in the indication fibromyalgia in Europe. This is their argumentation:

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Integrated Medicine concept for neuropathic pain at the Berlin congress (2010)

Treatment of neuropathic pain, an overview presented at the 3rd European Congress for Integrative Medicine,in Berlin, December 3rd, 2010. The founding fathers of the Institute of Neuropathic pain attended the above mentioned congress to present the integrated treatment concept for neuropathic pain to an audience of physicians interested in pain treatment. The director of research and development from the institute, professor Jan M. Keppel Hesselink, presented the multimodal therapy as it has been developed within the institute for the past years.

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Neuropathic pain treatment as presented by Dr Nadine Attal

The link here under contains a nice and crisp talk by Dr Nadine Attal. She is a neurologist and pain specialist, Director of the Pain Evaluation and Treatment Centre of Hôpital Ambroise Paré, France, and a member of the INSERM U 792 team. Dr Attal is a member of several scientific societies, including the Society for Neuroscience, the International Association for the Study of Pain and the American Pain Society. Dr Attal has authored 60 referenced journal articles and over 30 book chapters, has co-ordinated books on neuropathic pain in France, and is associate editor for the journal Pain. She recently co-chaired the European Federation of Neurological Societies (EFNS) guidelines on the pharmacological treatment of neuropathic pain and was involved in the EFNS guidelines on the assessment of neuropathic pain. She also recently joined the NeuroPsig management committee.

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Intractable neuropathic pain in Diabetes treated with palmitoylethanolamide and topical cream

Case description

A 53 year old famale patient suffered from diabetes type II since more than 10 years. She developed severe pains at the age of 48 and was totally refractory for many analgesics. Prescription of gabapentine, amitriptyline, pregabalin and carbamazepine remained unsuccesful in reducing her pains. On the numeric rating scale (NRS) for pain she scored 8 over 10.

She was a candidate for a spinal cord stimulator and wished first to follow our treatment protocol for treatment-resistant neuropathic pains, based on palmitoylethanolamide (Normast, PeaPure).

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Pharmacotherapy of painful neuropathy

In the journal JAMA, October 2009, was a description of a patient with diabetes mellitus and much discomfort from neuropathy. The doctor described the case, showed a list of drugs to see the usefulness of these values. Here on this table we see a number of recent rfindings and the relative strength of various painkillers for neuropathic pain. In this paper a clear message: Lyrica and Cymbalta are no better than older and cheaper drugs, which may be even better!

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Palmitoylethanolamide (PEA) at the 3rd European Congress for Integrated Medicine

A presentation of how to treat neuropathic pain in elderly and treatment refractory neuropathic pain patients prescribing the food for medical purposes and our own body-own compound palmitoylethanolamide (Normast®  and PeaPure® ): a presentation in Berlin at the 3rd European Congress for Integrated Medicine by Jan M. Keppel Hesselink, MD, PhD

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Ziconotide in chronic pain requiring intraspinal analgesia: orphan drug

Ziconotide is a man-made equivalent of a molecule composed of a 25-amino acid chain, which is found in the venom of a fish-eating marine snail, Conus magus. Ziconotide blocks the action of specific molecules found in nerve tissue, called N-type voltage-sensitive calcium channels. These molecules play an important role in chronic pain. Ziconotide is expected to decrease pain by blocking the function of these molecules.

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Pudendal neuralgia responding to a novel use of palmitoylethanolamide

Pudendal neuralgia is the most common and most disabling form of pelvic pain. It presents as unilateral or bilateral burning pain of the anterior or posterior perineum that is worse on sitting and relieved by standing, not usually associated with night pain.This pain is a cause of chronic, disabling, and often intractable perineal pain.

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Low dose Intravenous Ketamine in Refractory Neuropathic Pain

Treatment of refractory neuropathic pain is a clinical challenge. However, many new case reports and small clinical trials suggest that the N-methyl-D-aspartic acid (NMDA) receptor antagonists ketamine may be clinically useful in treating cases of neuropathic pain. Here a case report. This case report supports the idea that ketamine can be useful in the reduction of refractory chronic neuropathic pain and that the effect of ketamine can persist for many weeks after treatment.

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Efficacy and safety of palmitoylethanolamide in 610 pain patients

Dr Gatti and colleagues from the medical department oif the university of Rome (Italy) (Dipartimento di Medicina
Critica, del Dolore e delle Scienze Anestesiologiche,
Università degli Studi di Roma, Viale Oxford, 81,
00100 Roma, Italy)  described the efficacy and safety of palmitoylethanolamide (PEA) in 610 patients suffering from treatment refractory pains.  Titel of the 2012 article was: Palmitoylethanolamide in the Treatment
of Chronic Pain Caused by
Different Etiopathogenesis.

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Cancer and neuropathic pain

You are definitely familiar with symptoms as numbing, tingling, or prickling sensatiob,  after you have hit your funny bone, or your foot falls asleep. But for cancer patients, these sensations can be symptoms of either cancer itself, or, more often, a serious side effect of cancer therapy called neuropathy (injury to the nerves).

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Normast e PeaPure: informazioni palmitoilethanolamide

Questo sito fornisce informazioni su palmitoylethanolamide (PEA). PEA è disponibile come PeaPure, Normast, Pelvilen e altri nomi commerciali. Normast in Italia è disponibile in farmacia come alimento dietico destinato a fini medici speciale. PeaPure è prodotto nei Paesi Bassi e è disponibile per internet in tutto il mondo come unsupplemento inviato.

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Duloxetine (Cymbalta®) in urine incontinence and neuropathic pain

On 24 July 2008 the Committee for Medicinal Products for Human Use (CHMP) in Europe adopted a positive opinion, recommending to grant a marketing authorisation for the medicinal product Duloxetine  produced by Boehringer Ingelheim in capsules of 20 mg, 30 mg, 40 mg and 60 mg. The indications are: 

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Paclitaxel and long-lasting sensory neuropathy

Paclitaxel is an effective chemotherapeutic agent that is widely used for the treatment of several cancers, including breast and ovarium cancer. However, it induces disabling and potentially long-lasting sensory neuropathy. 

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Clinical relevant and electrophysiological effect of Palmitoylethanolamide

At the Third International Congress on Neuropathic Pain, Athens, Greece, May 27 – 30, 2010 A. Biasiotta, S. et al presented a poster which demonstrated a clinical relevant and electrophysiological measurable effect from a rather unknown compound, in some European countries registered as food for medical purposes, a body own molecule, palmitoylethanolamide (PEA, Normast© or PeaPure©).

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Breakthrough in the treatment of Sudeck’s dystropy (Chronic Regional Pain Syndrome, CRPS)

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Multimodal therapy in neuropathic pain: 2 is more than 1!

The famous Dutch surgeon Noordenbos wrote in 1959: "One-one synaptic transmission must be the exception rather than the rule in the nervous system. Any nerve cell located in the anterior horn. . . could hardly be expected to synapse at higher level with one such similar cell only. It will probably send ramifications to many other locations, and in turn be acted upon by the ramifications of many other cells. . . Far from being a continuous chain of short neurons, these fibres must constitute links in an extremely complicated nerve net in which, within limits, everything synapses more or less with everything else." It is clear that half a century later our therapy of pain is based on these deep insights of Noordenbos, and multimodal therapy is now the hallmark of how to treat neuropathic pain. This is because it is difficult to treat neuropathic pain with one drug only. In our centre we nearly always prescribe two or more oral drugs and mostly also topical creams and supplements together to get the patients out of the red zone of discomfort.

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Palmitoylethanolamide protects against side-effects anticancer drugs

Kahler’s disease is cancer of certain white blood cells, the plasma cells, and leads to death, mostly within 3-4 years. It is the second most frequent occuring forms of blood cancer, after non-Hodgkin’s disease. Initially patients can respond to chemotherapy, but treatment resistance often occurs. Furthermore, side effects such as nerve pain and nerve disfunctions (painful neuropathy) are dose limiting and thus optimal treatment of patients is not possible, as the chemotherapy needs to be stopped or reduced. Therfore patients cannot finish the course of chemotherapy and run a higher risk of relapse or recurrence of their cancer. Since years science searches for compounds to protect the nerve function, in order to enable patients suffering from MM to proceed being treated with chemotherapy.

Therefore it is highly important to point out that recently a natural occuring compound palmitoylethanolamide (PEA) has been identified in a clinical trial in MM patients, which indeed counteracts the side-effects of chemotherapy in blood cancer and restores nerve functions.

Italian neurologists from the neurological department of professor Cruccu, of the university of Rome, assessed the effect of PEA on pain and nerve function in patients with chemotherapy-induced painful neuropathy. 

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Syringomyelia, pain and its treatment

syringomyelia.jpg Although pain is a prominent symptom in patients suffering from syringomyelia, and this central neuropathic pain is very difficult to treat. However, more than half of all patients with syringomyelia suffer from symptoms related to central neuropathic pain. In the video you can see one of our patients, suffering from syringomyelia telling his story and reporting the effect of our treatment of the neuropathic pain:

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Pregabalin, the lidocaine plaster and duloxetine in refractory neuropathic pain

Numbers needed to treat in neuropathic pain are not very impressive. If you would tell your patient, I have to treat at least 5 patients like you in order to help one of those patients reach a pain reduction of 50%..imagine how many patients would frown and say…excuse me? (if they are British that is..). Because patients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain, the opening sentence of a new (2011) article on refractory neuropathic pain, ‘Pregabalin, the lidocaine plaster and duloxetine in patients with refractory neuropathic pain: a systematic review’ by Melanie Plested and collegues, among which one works at Pfizer’s (interesting..!).

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Palmitoylethanolamide (PEA) for neuropathic pain

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Palmitoylethanolamide: in 2012 more than 300 entries in pubmed for this interesting molecule!

The internationalizarion of PEA started at the Third International Congress on Neuropathic Pain, Athens, Greece, May 27 – 30, 2010.

A. Biasiotta, S. et al presented a poster which demonstrated a clinical relevant and electrophysiological measurable effect from this rather unknown compound classified as medical food, palmitoylethanolamide. The compound is available as dietfood for medical purposes (brandname Normast) in various European contries and under the brandname PeaPure (a supplement) via the internet.

This is very interesting for doctors as well as patients, as PEA is an endogenious fatty acid without any troublesome side-effects and easy to use to reduce pain, even together with other drugs.

Lipids like N-palmitoylethanolamine can act as signaling molecules, activating intracellular and membrane-associated receptors to regulate physiological functions. The signaling lipid PEA is known to activate intracellular, nuclear and membrane-associated receptors and regulate many physiological functions related to the inflammatory cascade, and thus is of high interest in the treatment of neuropathic, or gliopathic pain.

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Normast, Pelvilen, PeaPure: some differences and similarities

Normast, Pelvilen, PeaPure: we will discuss some differences and similarities of these three nutraceuticals. Palmitoylethanolamide is the active ingredient in all three. Normast is the Italian branded nutraceutical, available in Italy probably since 2007. Normast was developed since the end of last year, and the name Normast refers to the normalization of mast cell hyperactvity. The brandname Normast has been created in 2005.

Normast is the brand name of the in Italy produced palmitoylethanolamide version, Pelvilen consists of 400 and 200 mg tablets, and PeaPure is a brand introduced in 2012 by the company Russell Science Ltd, produced in the Netherlands.

 

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Topiramate to treat neuropathic pain

Topiramate is a drug we should not forget in treating patients suffering from neuropathic pain.  Especially not for patients with refractory neuropathic pain, that is if other drugs do not help.

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