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Tremont-Lukats IW, Challapalli V, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetics to relieve neuropathic pain: a systematic review and meta-analysis. Anesth Analg 2005; 101:1738-1749. [PMID: 16301253 DOI: 10.1213/01.ane.0000186348.86792.38] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We reviewed randomized controlled trials to determine the efficacy and safety of systemically administered local anesthetics compared with placebo or active drugs. Of 41 retrieved studies, 27 trials of diverse quality were included in the systematic review. Ten lidocaine and nine mexiletine trials had data suitable for meta-analysis (n = 706 patients total). Lidocaine (most commonly 5 mg/kg IV over 30-60 min) and mexiletine (median dose, 600 mg daily) were superior to placebo (weighted mean difference on a 0-100 mm pain intensity visual analog scale = -10.60; 95% confidence interval: -14.52 to -6.68; P < 0.00001) and equal to morphine, gabapentin, amitriptyline, and amantadine (weighted mean difference = -0.60; 95% confidence interval: -6.96 to 5.75) for neuropathic pain. The therapeutic benefit was more consistent for peripheral pain (trauma, diabetes) and central pain. The most common adverse effects of lidocaine and mexiletine were drowsiness, fatigue, nausea, and dizziness. The adverse event rate for systemically administered local anesthetics was more than for placebo but equivalent to morphine, amitriptyline, or gabapentin (odds ratio: 1.23; 95% confidence interval: 0.22 to 6.90). Lidocaine and mexiletine produced no major adverse events in controlled clinical trials, were superior to placebo to relieve neuropathic pain, and were as effective as other analgesics used for this condition.
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Affiliation(s)
- Ivo W Tremont-Lukats
- *Department of Neurology, Medical University of South Carolina, Charleston, SC; †Department of Anesthesiology and Critical Care, University of Chicago Hospitals, Chicago, IL; ‡Department of Anesthesiology, and §Institute for Clinical Research and Health Policy Studies Tufts-New England Medical Center, Boston, MA
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Challapalli V, Tremont-Lukats IW, McNicol ED, Lau J, Carr DB. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev 2005; 2005:CD003345. [PMID: 16235318 PMCID: PMC6483498 DOI: 10.1002/14651858.cd003345.pub2] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain (Keats 1951; Gilbert 1951; De Clive-Lowe 1958; Bartlett 1961). Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients (Boas 1982; Lindblom 1984; Petersen 1986; Dunlop 1988; Bach 1990; Awerbuch 1990). With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy. OBJECTIVES To evaluate pain relief and adverse effect rates between systemic local anesthetic-type drugs and other control interventions. SEARCH STRATEGY We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews. SELECTION CRITERIA We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause. DATA COLLECTION AND ANALYSIS We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively. MAIN RESULTS Thirty-two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty-one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = -11; 95% CI: -15 to -7; P <0.00001], and limited data showed no difference in efficacy (WMD = -0.6; 95% CI: -7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life-threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias. AUTHORS' CONCLUSIONS Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful.
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Abstract
This article is the second in a two-part series which explores pain and its management from a physiological perspective. Nurses play an important role in assessing and managing pain. Effective pain management by nurses requires them to have an understanding of the biological basis of the pain interventions which may be used to control pain. This article emphasizes the importance of pain assessment as a precursor for effective pain management and explores the biological basis of pain interventions which contribute to pain control. The role of non-pharmacological approaches in alleviating pain and their actions which contribute to pain relief are explored. The three main types of pharmaceutical agents used, non-opioids, opioids and adjuvant drugs, are introduced and their mechanisms of actions discussed.
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Affiliation(s)
- Helen Godfrey
- Faculty of Health and Social Care, University of the West of England, Bristol, UK
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Shao PP, Ok D, Fisher MH, Garcia ML, Kaczorowski GJ, Li C, Lyons KA, Martin WJ, Meinke PT, Priest BT, Smith MM, Wyvratt MJ, Ye F, Parsons WH. Novel cyclopentane dicarboxamide sodium channel blockers as a potential treatment for chronic pain. Bioorg Med Chem Lett 2005; 15:1901-7. [PMID: 15780630 DOI: 10.1016/j.bmcl.2005.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Revised: 01/31/2005] [Accepted: 02/01/2005] [Indexed: 11/20/2022]
Abstract
A series of new voltage-gated sodium channel blockers were prepared based on the screening lead succinic diamide BPBTS. Replacement of the succinimide linker with the more rigid cyclic 1,2-trans-diamide linker was well tolerated. N-Methylation on the biphenylsulfonamide side of the amide moiety significantly reduced the clearance rate in rat pharmacokinetic studies.
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Affiliation(s)
- Pengchang P Shao
- Department of Medicinal Chemistry, Merck Research Laboratories, Rahway, NJ 07065, USA
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Liang J, Brochu RM, Cohen CJ, Dick IE, Felix JP, Fisher MH, Garcia ML, Kaczorowski GJ, Lyons KA, Meinke PT, Priest BT, Schmalhofer WA, Smith MM, Tarpley JW, Williams BS, Martin WJ, Parsons WH. Discovery of potent and use-dependent sodium channel blockers for treatment of chronic pain. Bioorg Med Chem Lett 2005; 15:2943-7. [PMID: 15878274 DOI: 10.1016/j.bmcl.2005.02.093] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Revised: 02/18/2005] [Accepted: 02/22/2005] [Indexed: 11/18/2022]
Abstract
A new series of voltage-gated sodium channel blockers with potential for treatment of chronic pain is reported. Systematic structure-activity relationship studies, starting with compound 1, led to identification of potent analogs that displayed use-dependent block of sodium channels, were efficacious in pain models in vivo, and most importantly, were devoid of activity against the cardiac potassium channel hERG.
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Affiliation(s)
- Jun Liang
- Department of Medicinal Chemistry, Merck Research Laboratories, Rahway, NJ 07065, USA.
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Fisher A, Zakrzewska JM, Patsalos PN. Trigeminal neuralgia: current treatments and future developments. Expert Opin Emerg Drugs 2005; 8:123-43. [PMID: 14610917 DOI: 10.1517/14728214.8.1.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Trigeminal neuralgia is a rare condition in which patients experience brief, unilateral recurrent episodes of sharp paroxysms of pain that can occur spontaneously or be induced by physical triggers. Although current pharmacotherapy allows most patients at least some degree of comfort, there remains a substantial number who do not have adequate pain management. This can arise as a consequence of the disorder proving to be refractory to drug treatment in an individual, or the manifestation of drug-related side effects at therapeutic doses. When this occurs, the only treatment option is a surgical procedure, which may vary in its level of invasiveness and effect. Therefore, there is a substantial need for new antineuralgic drugs. The aim of this review is to highlight the current pharmacotherapies and those emerging drug treatments which will invariably enhance the treatment options of patients with trigeminal neuralgia.
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Affiliation(s)
- Andrew Fisher
- Pharmacology and Therapeutics Unit, Department of Clinical and Experimental Epilepsy, Institute of Neurology, Queen Square, London WC1N 3BG, UK
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Pjević M, Patarica-Huber E, Radovanović D, Vicković S. [Neuropathic pain due to malignancy: mechanisms, clinical manifestations and therapy]. ACTA ACUST UNITED AC 2004; 57:33-40. [PMID: 15327188 DOI: 10.2298/mpns0402033p] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Neuropathic pain in cancer patients requires a focused clinical evaluation based on knowledge of common neuropathic pain syndromes. DEFINITION Neuropathic pain is a non-nociceptive pain or "deafferentation" pain, which suggests abnormal production of impulses by neural tissue that is separated from afferent input. Impulses arise from the peripheral nervous system or central nervous system. CAUSES OF NEUROPATHIC PAIN DUE TO MALIGNANCY: Neuropathic pain is caused directly by cancer-related pathology (compression/infiltration of nerve tissue, combination of compression/infiltration) or by diagnostic and therapeutic procedures (surgical procedures, chemotherapy, radiotherapy). MECHANISMS Pathophysiological mechanisms are very complex and still not clear enough. Neuropathic pain is generated by electrical hyperactivity of neurons along the pain pathways. Peripheral mechanisms (primary sensitization of nerve endings, ectopically generated action potentials within damaged nerves, abnormal electrogenesis within sensory ganglia) and central mechanisms (loss of input from peripheral nociceptors into dorsal horn, aberrant sprouting within dorsal horn, central sensitization, loss of inhibitory interneurons, mechanisms at higher centers) are involved. DIAGNOSIS The quality of pain presents as spontaneous pain (continuous and paroxysmal), abnormal pain (allodynia, hyperalgesia, hyperpathia), paroxysmal pain. CLINICAL MANIFESTATIONS Clinically, neuropathic pain is described as the pain in the peripheral nerve (cranial nerves, other mononeuropathies, radiculopathy, plexopathy, paraneoplastic peripheral neuropathy) and relatively infrequent, central pain syndrome. THERAPY Treatment of neuropathic pain remains a challenge for clinicians, because there is no accepted algorithm for analgesic treatment of neuropathic pain. Pharmacotherapy is considered to be the first line therapy. Opioids combined with non-steroidal antiinflammatory drugs are warranted. If patient is relatively unresponsive to an opioid, a trial with adjuvant analgesics might be considered. Tricyclic antidepressants might be selected for patients with continuous dysesthesia, and anticonvulsants might be used if the pain is predominanty lancinating or paroxysmal. The complexity of neuropathic syndromes and underlying etiologic mechanisms warrant clinical trials to determine appropriate treatment.
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Abstract
The first article in this series explored epidemiology and patterns of pain in advanced disease, non-pharmacological treatments, and the use of opioids to manage pain. This second article examines the use of non-opioid drugs and anaesthetic interventions for pain relief in advanced disease. It also discusses an approach to managing analgesia in dying patients and finally looks at future developments.
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Affiliation(s)
- E J Hall
- St Christopher's Hospice, London, UK.
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Chow TKF, To E, Goodchild CS, McNeil JJ. A simple, fast, easy method to identify the evidence base in pain-relief research: validation of a computer search strategy used alone to identify quality randomized controlled trials. Anesth Analg 2004; 98:1557-1565. [PMID: 15155305 DOI: 10.1213/01.ane.0000114071.78448.2d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Clinicians need a simple, fast, reliable, and inexpensive way of identifying the evidence base relevant to their clinical practice. It is often believed that the only way to identify all relevant evidence is to perform hand-searches of the literature to supplement computer searches; this is complex and labor intensive. However, most of quality randomized controlled trials cited in systematic reviews in pain medicine are listed in computer databases. We performed two studies to investigate the efficiency-in terms of sensitivity, specificity, and precision-of three computer search strategies: Optimally Sensitive Search Strategy, which is used by the Cochrane Collaboration; RCT.pt, a standard MEDLINE strategy; and DBRCT.af, which is a new single-line computer algorithm based on the assumption that double-blinded, randomized controlled trials would be indexed with "double-blind," "random," or variations of these terms in MEDLINE and EMBASE. DBRCT.af was found to be highly sensitive (97%) in identifying quality randomized controlled trials in pain medicine. The precision (ratio of randomized controlled trials to the number of nonrandomized trials identified) was 82%, and the specificity in excluding the nonrandomized controlled trials was 98%. We conclude that clinicians can now use DBRCT.af to update and conduct de novo systematic reviews in pain-relief research. IMPLICATIONS Quality evidence about what is good clinical practice in pain treatment is buried in the medical literature among large quantities of other information. This article describes how any clinician with access to the Internet can identify those quality studies reliably, quickly, and inexpensively.
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Affiliation(s)
- Tony K F Chow
- *Department of Anaesthesia, Monash University, Monash Medical Centre, Clayton, Victoria, Australia; †Templestowe District Medical Centre, Templestowe, Victoria, Australia; and ‡Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Prahran, Victoria, Australia
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Koppert W, Weigand M, Neumann F, Sittl R, Schuettler J, Schmelz M, Hering W. Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesth Analg 2004; 98:1050-1055. [PMID: 15041597 DOI: 10.1213/01.ane.0000104582.71710.ee] [Citation(s) in RCA: 235] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Sodium channel blockers are approved for IV administration in the treatment of neuropathic pain states. Preclinical studies have suggested antihyperalgesic effects on the peripheral and central nervous system. Our objective in this study was to determine the time course of the analgesic and antihyperalgesic mechanisms of perioperative lidocaine administration. Forty patients undergoing major abdominal surgery participated in this randomized and double-blinded study. Twenty patients received lidocaine 2% (bolus injection of 1.5 mg/kg in 10 min followed by an IV infusion of 1.5 mg. kg(-1). h(-1)), and 20 patients received saline placebo. The infusion started 30 min before skin incision and was stopped 1 h after the end of surgery. Lidocaine blood concentrations were measured. Postoperative pain ratings (numeric rating scale of 0-10) and morphine consumption (patient-controlled analgesia) were assessed up to 72 h after surgery. Mean lidocaine levels during surgery were 1.9 +/- 0.7 microg/mL. Patient-controlled analgesia with morphine produced good postoperative analgesia (numeric rating scale at rest, <or=3; 90%-95%; no group differences). Patients who received lidocaine reported less pain during movement and needed less morphine during the first 72 h after surgery (103.1 +/- 72.0 mg versus 159.0 +/- 73.3 mg; Student's t-test; P < 0.05). Because this opioid-sparing effect was most pronounced on the third postoperative day, IV lidocaine may have a true preventive analgesic activity, most likely by preventing the induction of central hyperalgesia in a clinically relevant manner. IMPLICATIONS The perioperative administration of systemic small-dose lidocaine reduces pain during surgery associated with the development of pronounced central hyperalgesia, presumably by affecting mechanoinsensitive nociceptors, because these have been linked to the induction of central sensitization and were shown to be particularly sensitive to small-dose lidocaine.
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Affiliation(s)
- Wolfgang Koppert
- *Department of Anesthesiology, University of Erlangen, Erlangen, Germany; †Department of Anesthesiology Mannheim, University of Heidelberg, Mannheim, Germany; and ‡Department of Anesthesiology, St. Marien Hospital Siegen, Siegen, Germany
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Petersen KL, Rowbotham MC. Will ion-channel blockers be useful for management of nonneuropathic pain? THE JOURNAL OF PAIN 2003; 1:26-34. [PMID: 14622840 DOI: 10.1054/jpai.2000.9822] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For neuropathic pain, there is evidence that the analgesic effect of intravenous sodium-channel blockers is robust and dose dependent. Oral agents are less impressive, but efficacious nonetheless, especially at higher doses. Despite the evidence from animal studies for a role of sodium channels in inflammatory hyperalgesia, the clinical evidence of analgesic effect of oral and intravenous sodium channel blockers in both acute and chronic nonneuropathic pain is equivocal. The results to date from human experimental pain models suggest a lack of effect of systemic lidocaine on acute nociceptive pain and that the effect on cutaneous hyperalgesia is modest, at best. Furthermore, the literature suggests that the systemic lidocaine analgesia is both dose and diagnosis dependent.
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Affiliation(s)
- K L Petersen
- Department of Neurology, UCSF Pain Clinical Research Center, 94115, USA.
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Affiliation(s)
- David Borsook
- Descartes Therapeutics, Inc., 790 Memorial Drive, Suite 104, Cambridge, MA, USA.
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63
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Abstract
Pain caused by dysfunction or damage to the peripheral or central nervous system is typified by the symptoms described by patients with painful diabetic neuropathy, post-herpetic neuralgia and central poststroke pain. All these conditions are more common in the elderly. Neuropathic pain has long been recognised as one of the more difficult types of pain to treat; however, with the current emphasis on providing a multidisciplinary assessment and approach to management, more patients will be offered relief of their symptoms and an improved quality of life. Despite the use of combination drug therapy, adequate pain relief in the elderly is difficult to achieve without adverse effects. In an attempt to minimise these it is important to include non-drug treatment options in the management plan. Lifestyle changes and environmental modification, together with encouragement to adopt an appropriate exercise programme and an emphasis on maintaining mobility and independence should always be considered. Interventional therapy ranging from simple nerve blocks to intrathecal drug delivery can be of value. Drug treatment remains the mainstay of therapy. Tricyclic antidepressants such as amitriptyline, while having significant adverse effects in the elderly, have a number needed to treat (NNT) of 3.5 for 50% pain relief in diabetic neuropathy and 2.1 for 50% pain relief in postherpetic neuralgia. The newer antiepileptic drugs, such as gabapentin, appear to have a better adverse effect profile and provide similar efficacy with the NNT for treating painful diabetic neuropathy being 3.7 and 3.2 for treating pain in postherpetic neuralgia. As our understanding of the complexities of the pain processes increases, we are becoming more able to appropriately combine treatments to achieve not only improved pain relief but also improved function.
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Affiliation(s)
- Mahmood Ahmad
- Western Australian Pain Management Center, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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Abstract
Episodic pain is a common problem for patients with advanced cancer and is often difficult to manage successfully. In this article, the daily variations in cancer-related episodic pain in a patient with metastatic lung cancer are described. The definition, etiology, prevalence, and pharmacological management of episodic pain are also reviewed
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Abstract
Neuropathic pain is a distressing, poorly understood and under-treated condition. In this review we seek to examine the definition and classification of neuropathic pain, summarize clinically important underlying mechanisms, outline current management strategies and look at future directions for research and therapy.
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Affiliation(s)
- T E Smith
- Pain Relief Unit, Kings College Hospital, London SE5 9RS
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Abstract
Neuropathic pain is often inadequately controlled by conventional analgesics. Because the aetiology of neuropathic pain is only partially understood, specific treatment approaches have not been defined. A variety of pharmacological treatments have been proposed. However, for only a small minority of drugs used in neuropathic pain has the scientific evidence been evaluated in a satisfactory manner. The present review of the recent literature reveals the potential of certain novel drugs in treatment of neuropathic pain.
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Affiliation(s)
- A Kopf
- Department for Anaesthesiology and Intensive Care, Benjamin Franklin University Hospital, Freie Universität Berlin, Berlin, Germany.
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67
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Stereospecific synthesis of mexiletine and related compounds: Mitsunobu versus Williamson reaction. ACTA ACUST UNITED AC 2000. [DOI: 10.1016/s0957-4166(00)00332-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Nash TP. Treatment options in painful diabetic neuropathy. ACTA NEUROLOGICA SCANDINAVICA. SUPPLEMENTUM 2000; 173:36-42; discussion 48-52. [PMID: 10819090 DOI: 10.1111/j.1600-0404.1999.tb07388.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Diabetic neuropathy is common in patients with diabetes mellitus, and 7.5% of diabetics experience pain from diabetic neuropathy. Complications of diabetes mellitus are more common where control of the disease is not optimal. By improving the control of the disease, both the neuropathy and the pain it can produce may be improved. The pain of diabetic neuropathy can frequently be controlled using analgesics, antidepressants, anticonvulsants, topical capsaicin, and neuromodulation, either alone or in any combination.
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Affiliation(s)
- T P Nash
- Walton Centre for Neurology and Neurosurgery, University of Liverpool, United Kingdom
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Moore RA, McQuay H. Reply to Arnér and Meyerson. Pain 2000. [DOI: 10.1016/s0304-3959(99)00201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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