Instituut voor Neuropathische Pijn
English articles Treatment Neuropathic pain treatment as presented by Dr Nadine Attal
| Neuropathic pain treatment as presented by Dr Nadine Attal |
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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.
http://www.painin21stcentury.com/speaker-nadineattal.html Nadine presents the definition of neuropathic pain and points out that the definition is currently on the move. She presents epidemiological data on neuropathic pain in France, showing that 5-7% of the general population have neuropathic pain syndromes. Most common neuropathic pain syndrome is the radiculopathy. She discussed the various mechanisms behind neuropathic pain such as excitability (lidocaine, anti-epileptics), sodium channel blockers, decending control mechanisms (antidepressants) and central sensitization (pregabelin). Antidepressants are the most popular therapy in neuropathic pain, were amitriptyline is most active and the SSRI's most weak. Duloxetine is a bit more active compared to SSRI and has intermediate efficacy. Among the antiepileptics, the alpha2delta antagonists, such as pregabelin are a step forweard. The alpha2dela receptor is linked to a calciumchannel. Many trials (16+) have been conducted with these antagonists in PHN and PN. For gabapentine no clear dose-response curve exists, but it does exist for pregabeline, 600 mg is more effective compared to 300 mg. Nadine made the point that this might be due to the better bioavailability. Regarding the sodium channel blockers there are many conflicting results in the field of diabetic painful neuropathy; some sodiumchannel blockers are effective in RCT's others are not. The idea that opiates are not effective in neuropathic pain has been rejected. The building of a treatment allgorithm is complicated, as there are only very few comparable drug trials, most RCT's are dealing with one drug only versus placebo. Meta-analysis show that nearly all drugs are only moderate active, and NNT are not less than 3-4...! If selecting an analgesic, considering other symptoms as sleep, depression and anxiety, or allodynia help to select the best first line drug. For instance, if allodynia is clearly present, topical lidocaine should be considered. And in general TENS should not be forgotten. Future targets might be neuroglia, Cannabinoids and vanniloid agonists, as well as botulinum (intradermally in painful area in case of allodynia). May 2010, Jan M. Keppel Hesselink, MD, PhD |