Abstract A number of different treatments for neuropathic pain have been studied, but the literature is sizable, rapidly evolving, and lacks important information about practical aspects of patient ...management. Under the auspices of the International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG), a consensus process was used to develop evidence-based guidelines for the pharmacologic management of neuropathic pain that take into account clinical efficacy, adverse effects, impact on health-related quality of life, convenience, and costs. On the basis of randomized clinical trials, medications recommended as first-line treatments for neuropathic pain included certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel α2 -δ ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications that generally would be used as third-line treatments include certain other antidepressant and antiepileptic medications, topical capsaicin, mexiletine, and N -methyl- d -aspartate receptor antagonists. Two other national and international associations recently published pharmacologic treatment guidelines for neuropathic pain, which are summarized and contrasted with the NeuPSIG recommendations. Recent guidelines for the use of neurostimulation for the treatment of neuropathic pain also are summarized. For all treatments for neuropathic pain, long-term studies, head-to-head comparisons, and studies of treatment combinations are a priority for future research.
Abstract Objectives Pain management in emergency department (ED) patients is variable and often inadequate. This study sought to (1) describe the variability in intravenous opioid dosing and (2) ...compare the outcomes that result from the most commonly prescribed opioid doses. Methods This prospective cohort study enrolled emergency patients who were prescribed intravenous morphine or hydromorphone as their initial analgesic. Subjects were interviewed at the time of opioid administration and 1 to 2 hours after opioid administration. Outcomes included the numeric pain score change (using a 0-10 scale), the proportion achieving a 50% pain score reduction, and the proportion developing side effects. Logistic regression was used to assess the effects of demographic, clinical, and treatment variables on outcomes. Results Six hundred ninety-one patients were analyzed. Initial equianalgesic dosages varied by a factor of 27 (from 1 mg morphine to 4 mg hydromorphone). Opioid dose titration occurred in only 21% of patients. Outcomes were similar across the range of opioid dosages before and after adjusting for potentially confounding variables. Among patients not taking opioids at home who received a total of 4 mg of morphine or less. 48% achieved at least a 50% pain score reduction and 60% did not want additional analgesics. Conclusions We found marked opioid dosing variability and infrequent opioid dose titration. A substantial number of ED patients with severe pain responded well to relatively low opioid dosages. Improved ability to predict opioid dose requirements and strategies that increase the use of opioid dose titration in ED patients are needed.
The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain recently sponsored the development of evidence-based guidelines for the pharmacological treatment of ...neuropathic pain. Tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel α2 -δ ligands (ie, gabapentin and pregabalin), and topical lidocaine were recommended as first-line treatment options on the basis of the results of randomized clinical trials. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in certain clinical circumstances. Results of several recent clinical trials have become available since the development of these guidelines. These studies have examined botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies in various neuropathic pain conditions. The increasing number of negative clinical trials of pharmacological treatments for neuropathic pain and ambiguities in the interpretation of these negative trials must also be considered in developing treatment guidelines. The objectives of the current article are to review the Neuropathic Pain Special Interest Group guidelines for the pharmacological management of neuropathic pain and to provide a brief overview of these recent studies.
OBJECTIVES: To compare the net health effects and costs resulting from treatment with different first‐line postherpetic neuralgia (PHN) medications.
DESIGN: Cost–utility analysis using published ...literature.
PARTICIPANTS: Hypothetical cohort of patients aged 60 to 80 with PHN.
INTERVENTIONS: Desipramine 100 mg/d, gabapentin 1,800 mg/d, and pregabalin 450 mg/d.
MEASUREMENTS: A decision model was designed to describe possible treatment outcomes, including different combinations of analgesia and side effects, during the first 3 months of therapy for moderate to severe PHN. The main outcome was cost per quality‐adjusted life‐year (QALY) gained. Costs were estimated using the perspective of a third‐party payer. Multivariate, univariate, and probabilistic sensitivity analyses were performed, and the time frame of the model was varied to 1‐month and 6‐month horizons.
RESULTS: Desipramine was more effective and less expensive than gabapentin or pregabalin (dominant) under all conditions tested. Gabapentin was more effective than pregabalin but at an incremental cost of $216,000/QALY. Below $140/month, gabapentin became more cost‐effective than pregabalin at a threshold of $50,000/QALY, and below $115/month gabapentin dominated pregabalin.
CONCLUSION: Desipramine appears to be more effective and less expensive than gabapentin or pregabalin for the treatment of older patients with PHN in whom it is not contraindicated. After its price falls, generic gabapentin will likely be more cost‐effective than pregabalin.
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