00:01
Now, let's talk about step four. What medical treatments exist for patients with neuropathic pain?
Well, there are a number of types of medicines that we think about that treat neuropathic pain.
00:13
We can use one or often, a combination as we're considering rational polypharmacy
in patients with severe pain disorders.
00:21
One category that I'd like for you to remember is anticonvulsants.
00:24
And we think about a number of anticonvulsants that can be used to treat neuropathic pain.
00:29
Gabapentin, pregabalin, and carbamazepine can be particularly effective,
often, for peripheral localizations or peripheral causes of neuropathic pain.
00:39
Oxcarbazepine and others like Depakote, valproic acid, or topiramate can be used.
00:45
It may be effective in central neuropathic pain syndromes.
00:49
We think about antidepressants.
00:51
Duloxetine, venlafaxine, amitriptyline, nortriptyline, the two tricyclic antidepressants
as well as bupropion can be used to treat patients with neuropathic pain.
01:03
Topical agents can be used. Topical lidocaine either in a patch or cream or gel, topical capsaicin.
01:10
Topical gabapentin can be compounded and used as well as topical ketamine.
01:15
With topical agents, there's reduced systemic absorption in delivery of drug right to the peripheral nerves.
01:22
Topical TCAs, including topical amitriptyline can also be used.
01:27
Sometimes, we'll combine topical agents, one neuropathic,
a cream combination that I use is a combination of gabapentin, ketamine, and ketoprofen
which can be effective in various peripheral pain syndromes.
01:40
And in addition, amitriptyline, ketamine, and ketoprofen.
01:44
How do we think about using and selecting these agents for patients?
Well, there are a number of large groups that have come together to define, first, second, third,
or fourth line agents that can be used for patients with neuropathic pain.
01:59
I don't need you to remember all the details,
but see how we sequence our medications for peripheral pain syndromes
compared to central pain syndromes.
02:08
So here with these criteria in terms of diabetic neuropathy,
some of the first line agents are duloxetine, gabapentin, pregabalin, the TCAs and venlafaxine.
02:18
With post-herpetic neuralgia, also a peripheral pain syndrome,
we have a similar group, gabapentin, pregabalin, the TCAs and lidocaine patch
for that localized pain that we see with post-herpetic neuralgia.
02:30
In contrast, for the central nervous system syndromes
like trigeminal neuralgia, we see carbamazepine and oxcarbazepine as first line agents.
02:39
For central thalamic pain syndrome, gabapentin, pregabalin,
and the TCAs are often considered first line.
02:45
Tramadol, strong and weak opioids can be considered.
02:49
Lamotrigine and even the cannabinoids can be used for these patients where response is often incomplete.
02:56
There are other groups that have described similar criteria to consider treatment of neuropathic pain.
03:03
Again, we commonly see the TCAs, duloxetine, gabapentin, and pregabalin, as well as topical agents.
03:10
For trigeminal neuralgia, carbamazepine and oxcarbazepine are typically first line.
03:14
In addition to oral and topical agents, other non-medical interventions can be used.
03:19
Occipital or other nerve blocks can be effective when pain is localized to a specific nerve.
03:25
Spinal cord stimulators may help to reduce the central nervous system relay of pain.
03:31
Transcranial magnetic stimulation is increasingly being utilized and studied for the use of neuropathic pain,
as well as radiofrequent rhizotomy or treating a nerve that is resulting in localized pain
as well as other interventions.
03:47
We also want to think about complementary and alternative therapies
integrated in to our medical and surgical treatments.
03:53
Things like yoga, acupuncture, meditation, massage, stress relaxation techniques
have been studied in a variety of neuropathic pain syndromes
and can be helpful adjuncts in patients with neuropathic pain.