Neuropathic Pain: Treatment

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.