Neuropathic Pain Therapy: Evidence-Based Recommendations

[MeSci]

This paper isn't specifically relevant to M.E. patients, but hopefully has some useful info. It's from February, but I couldn't find it here.

Lancet Neurol. 2015 Feb;14(2):162-73

Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis.
Finnerup NB1, Attal N2, Haroutounian S3, McNicol E4, Baron R5, Dworkin RH6, Gilron I7, Haanpää M8, Hansson P9, Jensen TS10, Kamerman PR11, Lund K1, Moore A12, Raja SN13, Rice AS14, Rowbotham M15, Sena E16, Siddall P17, Smith BH18, Wallace M19.

Abstract

BACKGROUND:

New drug treatments, clinical trials, and standards of quality for assessment of evidence justify an update of evidence-based recommendations for the pharmacological treatment of neuropathic pain. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), we revised the Special Interest Group on Neuropathic Pain (NeuPSIG) recommendations for the pharmacotherapy of neuropathic pain based on the results of a systematic review and meta-analysis.

METHODS:

Between April, 2013, and January, 2014, NeuPSIG of the International Association for the Study of Pain did a systematic review and meta-analysis of randomised, double-blind studies of oral and topical pharmacotherapy for neuropathic pain, including studies published in peer-reviewed journals since January, 1966, and unpublished trials retrieved from ClinicalTrials.gov and websites of pharmaceutical companies. We used number needed to treat (NNT) for 50% pain relief as a primary measure and assessed publication bias; NNT was calculated with the fixed-effects Mantel-Haenszel method.

FINDINGS:

229 studies were included in the meta-analysis. Analysis of publication bias suggested a 10% overstatement of treatment effects. Studies published in peer-reviewed journals reported greater effects than did unpublished studies (r(2) 9·3%, p=0·009). Trial outcomes were generally modest: in particular, combined NNTs were 6·4 (95% CI 5·2-8·4) for serotonin-noradrenaline reuptake inhibitors, mainly including duloxetine (nine of 14 studies); 7·7 (6·5-9·4) for pregabalin; 7·2 (5·9-9·21) for gabapentin, including gabapentin extended release and enacarbil; and 10·6 (7·4-19·0) for capsaicin high-concentration patches. NNTs were lower for tricyclic antidepressants, strong opioids, tramadol, and botulinum toxin A, and undetermined for lidocaine patches. Based on GRADE, final quality of evidence was moderate or high for all treatments apart from lidocaine patches; tolerability and safety, and values and preferences were higher for topical drugs; and cost was lower for tricyclic antidepressants and tramadol. These findings permitted a strong recommendation for use and proposal as first-line treatment in neuropathic pain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin; a weak recommendation for use and proposal as second line for lidocaine patches, capsaicin high-concentration patches, and tramadol; and a weak recommendation for use and proposal as third line for strong opioids and botulinum toxin A. Topical agents and botulinum toxin A are recommended for peripheral neuropathic pain only.

INTERPRETATION:

Our results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest efficacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profiling probably account for moderate trial outcomes and should be taken into account in future studies.

FUNDING:

NeuPSIG of the International Association for the Study of Pain.

 

[minkeygirl]

@MeSci I cant read this (blurry vision right now).That Capsaicin and tricyclics only were 50% effective?

I had an epiphany over the weekend when I took some phenibut to sleep and the next day, besides being pleasantly high, I was in a good mood and had no pain until the middle of the afternoon when I started to come down.

I've had intermittent relief with Kava and Baclofen. Not much help with Trazodone. Lyrica and Gabapentin cause weight gain if I even think about them so they are out.

 

[MeSci]

@MeSci I cant read this (blurry vision right now).That Capsaicin and tricyclics only were 50% effective?

I had an epiphany over the weekend when I took some phenibut to sleep and the next day, besides being pleasantly high, I was in a good mood and had no pain until the middle of the afternoon when I started to come down.

I've had intermittent relief with Kava and Baclofen. Not much help with Trazodone. Lyrica and Gabapentin cause weight gain if I even think about them so they are out.

Phenibut sounds nice!

I hadn't actually read the paper - just posted it for the interest of pwME who get neuropathic pain (I don't).

I find the method of assessing efficacy a bit confusing actually, but it seems to be saying that 10.6 people have to be treated with capsaicin high-concentration patches to achieve 50% pain relief, and fewer need to be treated with tricyclics for equal effect, but the abstract doesn't state how many, and I don't have access to the full text.

 

[minkeygirl]

@MeSci thanks for translating. I gleaned there wasn't anything new but only picked up a few words here and there

Phenibut is awesome but it's just as addictive if not more than benzos so you can only take it 2-3 times a week max.

I save it for sleep if I've been struggling for a few days.