Flashcards in Neuromyalgia and Fibromyalgia Deck (80):
What are the two types of neuropathic pain?
What is a lesion?
What is disease neuropathic pain?
What is the pathophysiology of neuropathic pain?
Neuropathic injury stimulates sensitization and induces long-term abnormal neural activity along afferent pathways
Spinal cord dorsal horn neurons show excitatory responses and decreases in firing threshold
Persistent molecular changes result in potentiated changes in the peripheral, spinal, and cortical levels
When is neurologic pain typically the worst?
What are the 3 types of neuropathic pain?
What is the presentation of diabetic neuropathy?
Diffuse and symmetric length-dependent injury to peripheral nerves
How is diabetic neuropathy diagnosed?
Monofilament/tuning fork test
What is the presentation of post-herpetic neuralgia?
Burning, aching, electric shock like pain or itching associated with the outbreak of a HZV rash that continues after the resolution of the infection
How does age correlate to post-herpetic neuralgia?
The older the patient is at shingles onset, the more likely they are to have post-herpetic neuralgia
What can be administered w/in 72 hours of a shingles outbreak to prevent post-herpetic neuralgia?
What is the diagnosis of post-herpetic neuraliga?
Burning pain that continues for 90 days after resolution of a herpes zoster rash
What is the presentation of trigeminal neuralgia?
Pain that is sudden, unilateral, severe, brief, stabbing and recurrent episodes in one or more branches of the trigeminal nerve
How is trigeminal neuralgia diagnosed?
CT scan that shows:
Compression of the 5th cranial nerve
Structural abnormality of the 5th cranial nerve
How is fibromyalgia characterized?
Widespread musculoskeletal pain and tenderness
What are the neuropsychological sx of fibromyalgia?
What are common comorbidities of fibromyalgia?
Pelvic pain syndromes
Are men or women more likely to have fibromyalgia?
What is the pathophysiology of fibromyalgia?
Can be triggered by infection, metabolic/psychiatric comorbidities
Polymorphisms in the serotonin transporter gene and the enzyme that inactivates catecholamines
What is the diagnosis of fibromyalgia?
"Pain all over"
Typically above and below the waist on both sides of the body
Difficult to ignore
Severe in intensity
Present most of the day on most days for 3+ months
Routine labs are normal
Diagnosis of exclusion
What is the nonpharm treatment for neuropathic pain and fibromyalgia?
Management of comorbidities
What is the nonpharm treatment that is specific for neuropathic pain?
Ablation of nerve bundle (LAST LINE)
What are the anticonvulsants used in neuropathic pain and fibromyalgia?
What agents must be adjusted in renal impairment?
What is the MOA of pregabalin?
Binds to Ca channels and modulates excitatory neurotransmitters which affects nociception
How does pregabalin relate to gabapentin?
Pregabalin is a prodrug with a higher affinity
What is the only drug that is FDA apparoved for diabetic neuropathy?
What are the AEs of pregabalin and gabapentin?
(Gabapentin much worse)
What is the MOA of gabapentin?
Structurally related to GABA, binds throughout the brain and may modulate the release of excitatory neurotransmitters which affect nociception
What is the MOA of CBZ in neuropathic pain and fibromyalgia?
Modulates neurotransmitter activity at neuronal synapses and Na channels to decrease peripheral nerve excitability
What is CBZ chemically related to?
What are DDIs of CBZ?
What is FDA approved for trigeminal neuralgia?
What is the MOA of lamictal?
Inhibits the release of glutamate and stabilizes the nueronal membranes by inhibiting sodium channels
What are the AEs of CBZ?
What are the AEs of lamictal?
What are the DDIs of lamictal?
What can lamictal be used for?
Neuropathy related to HIV pain
What are the MOA of TCAs?
Modulate neurotransmitter activity at neuronal synapse at descending inhibitory spinal pathways
How does Amitripyline and imipramine work?
Inhibit presynaptic reuptake of NE and serotonin
How does despiramine work?
Inhibits presynpatic reuptake of NE
Does mood elevating properties of TCAs affect pain relief?
What are AEs of TCAs?
When should TCAs be given?
What is the MOA of SSRIs?
Decrease serotonin reuptake at the neuronal synapse at descending inhibitory spinal pathways
What are AEs of SSRIs?
What is the MOA of SNRIs?
Inhibits serotonin and NE reuptake at the neuronal synapse at descending inhibitory pathways in the CNS
Are SNRIs or SSRIs more effective for neuropathic pain?
What are AEs of SNRIs?
Increased bleeding risk
What is the MOA of capsaicin?
Works on the vanilloid 1 receptor (TRPV1) to cause local damage and defunctionalize pain sensory receptors' ability to send pain signals
Desensitizes sensory axons and inhibition of pain transmission initiation
Repeated application depletes the neuron of substance P and prevents re-accumulation
How is the capsaicin patch applied?
Applied in physicians office for 60 minutes
How many patches of capsaicin can be applied at one time?
How often can capsaicin treatment be repeated?
Every 3 months
How do we pretreat for capsaicin patches?
What are AEs of capsaicin?
Short term increases in BP and HR
Local erythema and pain
What is the MOA of topical lidocaine?
Interrupts peripheral nerve impulses
How many patches of lidocaine can be applied at the same time?
Which opioid has modest efficacy for fibromyalgia and neuropathy?
Which opioid can be used last line in diabetic neuropathy?
What can cyclobenzaprine be used for?
How does botulinum toxin work in pain?
Serotype A inhibits the secretion of substance P and calcitonin
How does alpha-lipoic acid work?
Antioxidant effect that causes improved nerve blood flow
When would alpha-lipoic acid be administered?
For use at the beginning to slow progression
What is benfotiamine?
Fat soluble vitamin B1
What are first line agents for diabetic neuropathy?
What are the second line agents for diabetic neuropathy?
What are third line agents for diabetic neuropathy?
What should not be used in diabetic neuropathy?
What are first line agents for post-herpetic neuralgia?
What is the second line agents for post-herpetic neuralgia?
What are first line agents for trigeminal neuralgia?
What are second line agents for trigeminal neuralgia?
How do we treat fibromyalgia?
Treatment is symptom specific
If the patient has fibromyalgia and difficulty sleeping, what medications should be given?
If the patient has fibromyalgia and depression/anxiety, what medication should be given?
What are second line agents for fibromyalgia?
What medications should be avoided in fibromyalgia?
Opioids and NSAIDs
What is the treatment for acute/subacute lower back pain?
Non-pharm treatment (heat, massage, acupuncture, spinal manipulation)
If pharm treatment is desired, NSAIDs and skeletal muscle relaxants are preferred
What is the initial treatment for chronic lower back pain?
Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation