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Neuropathic pain: guidelines simplify management.

Chronic neuropathic pain is common and debilitating, but new evidence-based guidelines promise to simplify the management of this type of pain by offering specific treatment recommendations.

Chronic neuropathic pain--caused by lesions in the peripheral and/or central nervous system--is associated with many conditions. Among the most common and well studied of these conditions are painful diabetic neuropathy, which affects an estimated 3 million people, and postherpetic neuralgia, which affects an estimated 1 million people, noted Robert H. Dworkin, Ph.D., lead author of the guidelines (Arch. Neurol. 60[11]:1524-34, 2003).

Other common underlying causes of chronic neuropathic pain include infections, trauma, metabolic abnormalities, chemotherapy, neurotoxins, and nerve compression, said Dr. Dworkin of the University of Rochester (N.Y.)

He and a team of international experts on pain management conducted a review of randomized controlled trials and identified five first-line drugs or drug classes that provide "statistically significant and clinically meaningful treatment benefits." These recommended first-line drugs are gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol, and tricyclic antidepressants.

Studies of chronic neuropathic pain have focused mainly on painful diabetic neuropathy and postherpetic neuralgia, and the Food and Drug Administration has approved medications for the treatment of only two specific pain syndromes: carbamazepine for trigeminal neuralgia, and gabapentin and the 5% lidocaine patch for postherpetic neuralgia. But most of the recommended first-line agents also have been studied in other types of neuropathic pain.

Gabapentin, for example, has been studied in painful diabetic neuropathy and postherpetic neuralgia as well as in mixed neuropathic pain syndromes, phantom limb pain, Guillain-Barre syndrome, and pain associated with spinal cord injury.

In making their recommendations, the team of experts considered safety, adverse effects, and drug interactions. The guidelines include information on these factors, as well as dosing, titration, and adequate duration of treatment trials. Also included are suggestions for selecting the appropriate first-line therapy for specific clinical conditions, using first-line medications sequentially or in combination, and selecting second-line agents.

In an editorial, Dr. Roger N. Rosenberg of the University of Texas Southwestern Medical Center called the guidelines "positive and optimistic" (Arch. Neurol. 60[11]:1520, 2003).

The message from these articles, and from another review on advances in the neurosurgical treatment of pain (published in the same issue of the journal), is that therapies for pain are effective and safe, and that the increasing understanding of the basic neurophysiology of pain will produce even more effective, safe, and cost-effective treatments, Dr. Rosenberg said.

BY SHARON WORCESTER

Tallahassee Bureau
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Title Annotation:Pain Medicine
Author:Worcester, Sharon
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Mar 1, 2004
Words:413
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