Neuropathic Pain

Question 1

what does gabapentin targget

Answer 1

calcium channel (central sensitization)

Question 2

what do TCAs target

Answer 2

NE/serotonin receptor

disinhibition

Question 3

what so SNRIs target

Answer 3

NE, serotonin (disinhibition)

Question 4

what does lidocaine target

Answer 4

sodium channels (peripheral)

Question 5

efficacy of neuropathic pain meds

Answer 5

not a lot of eveidednce
very few comparative trials suggest similarity
dont look at the NNT poor studies behind them
can consider them all the same and pick based on the patient

Question 6

should we use opioids

Answer 6

very low eficacy and lots of dependence and abuse so no

Question 7

is tramadol an exception

Answer 7

besides opioid receptor agonist its also inhibits NE and serotonin reuptake
lower abuse potential but still not that great

Question 8

what do we know about functioning

Answer 8

insufficient evidence regarding quality of life but we can assess this in our patients

Question 9

TCA side effects

Answer 9

constipation, dry mouth
weight gain
orthostatic hypotension
sedation

Question 10

TCA cautions

Answer 10

elderly, dementia, glaucoma, urinary retention, cardiac disease

Question 11

gabapentin and pregabalin SE

Answer 11

dizzy
sedation
peripheral edema

Question 12

gabapentin cautions

Answer 12

elderly
edema
fall risk
abuse potential

Question 13

SNRI SE

Answer 13

nausea - goes away with time
increased BP
dizziness

Question 14

SNRI cautions

Answer 14

hypertension

biploar

Question 15

tramadol SE

Answer 15

nausea
constipation
sedation
dizziness

Question 16

tramadol cautions

Answer 16

opioid dependence
addiction risk
seizure risk

Question 17

3 options worth a trial but just warn patient that most experience side effects

Answer 17

TCA
gabapentin
SNRI

Question 18

non pharms

Answer 18

meditation 
psychosocial 
CBT 
music
exercise? - good for other stuff 
heat and ice

Question 19

dosing trial for TCA

Answer 19

start 10-25 HS to 50-100HS

max 150

Question 20

dosing trial for gabepentin

Answer 20

start at 300mg/day then 300-900TID

max 1200TID - max dose just see a plateau and increase in SE

Question 21

dosing trial for pregabalin

Answer 21

start 75 BID then 150-300 BID

Question 22

dosing trial for duloxetine

Answer 22

start 30 mg then go up to 60mg

Question 23

dosing trial for venlafaine

Answer 23

37.5daily

then up to 150-225 daily

Question 24

how long is an adequate trial of meds

Answer 24

once reach the low end of the usual effective dose then 2-4 weeks

Question 25

onset for pain meds

Answer 25

1 week

Question 26

ways to incease dose

Answer 26

fast: increase 50-100% every 3 days
slow: increase 50-100% every week

Question 27

why do we start low and go slow

Answer 27

no rush
not worth risking harm to the patient
side effects may result in a loss of a viable option
higher doses have a low likelihood of resulting in greater benefit

Question 28

drugs to use if patient has depression or anxiety

Answer 28

TCA - but we tend not to use doses as high as in depression

SNRI

Question 29

drugs to use if patient has insomnia

Answer 29

gabapentin

TcA

Question 30

drug to use if patient has osteoarthritis

Answer 30

duloxetine

tramadol

Question 31

drug to use if patient has migraines

Answer 31

TCA

Question 32

monitoring timeline

Answer 32

1 week to se how their doing, side effects

2-4 weeks for efficacy: pain level and functioning

Question 33

if patient sees no benefit try

Answer 33

increase dose if not at upper dose

it at upper dose stop and switch

Question 34

if patient experiencing some benfit from med try

Answer 34

continue and maybe increase the dose or add another agent

Question 35

if side effects not tolerable try

Answer 35

if there was a benefit at a lower dose decrease the dose and add another agent
or stop and switch

Question 36

if med tolerable and effective reassess for ongoing need in

Answer 36

3 months

Question 37

should we use combination therapy

Answer 37

not a lot of evidence

may be beneficial to have ttwo diff moa?

Question 38

which two do we absolutely not combine

Answer 38

gabapentin + opioid

NNT = NNH

Question 39

lidocaine advantages

Answer 39

immediate onset

min systemic absorption

Question 40

capsaicin recommendation

Answer 40

doesnt work

burning just cuases a distraction

Question 41

topical option if very resistant to all treatments

Answer 41

ketamine

Question 42

patient counseling points

Answer 42

benefit
onset
side effects
cost/coverage