myalgias, arthralgias, neuralgias shawn jorgensen, md albany medical center aapm&r annual...
TRANSCRIPT
Myalgias, Arthralgias, NeuralgiasShawn Jorgensen, MDAlbany Medical CenterAAPM&R Annual AssemblyOctober 2015
DisclosuresNo financial disclosures
NeuralgiasNeuropathic pain
◦Estimated 4-8% prevalence (Moulin 2014)
◦Diabetics – 16% with painful neuropathy (Bril 2011)
◦Sources Central nervous system Peripheral nervous system
Focal peripheral mononeuropathies Radiculopathies Plexopathies Generalized peripheral neuropathies
Peripheral Neuropathic Pain Disorders of sensation associated with peripheral
neuropathy - definitions◦ Neuropathic pain
“Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.” (Treede 2008)
◦ Peripheral neuropathic pain Only the peripheral portion of the somatosensory system (e.g.
not central poststroke pain)
◦ Dysethsesia An unpleasant abnormal sensation, whether spontaneous or
evoked. (IASP 1994)
◦ Hyperalgesia Increased pain from a stimulus that normally provokes pain.
(IASP 1994)
◦ Allodynia Pain due to a stimulus that does not normally provoke pain.
(IASP 1994)
Peripheral Neuropathic Pain
Neuropathies◦Breaking down neuropathies - Axes
Time of onset Fiber size Modality (sensory, motor, autonomic) Neuron / myelin Aspect of neuron (soma, axon) Length-dependence
Peripheral Neuropathic Pain
Fiber Size◦Small fiber
Symptoms Pain, burning (dysesthesia)
Physical exam: Normal strength Normal vibration, proprioception, light touch Abnormal pinprick, temperature, crude touch Normal reflexes
NCS Normal
Peripheral Neuropathic Pain
Fiber Size◦Large
Symmptoms Tingling (parasthesia)
Physical exam Possibly decreased strength Decreased vibration, proprioception, light touch Normal pinprick, temperature, crude touch Diminished reflexes
NCS Abnormal NCS
Peripheral Neuropathic Pain
Length-dependence◦Length-depenent (distal symmetrical)
Most neuropathies
◦Non-length dependent Multifocal neuropathies
Mononeuropathy mutliplex Lewis-Sumner syndrome HNPP
Autoimmune demyelinating CIDP, AIDP
Ganglionopathy/neuronopathy
Stockingandglovedistribution
Peripheral Neuropathic Pain
Other problems resulting from peripheral neuropathy◦Loss of protective sensation◦Ataxia◦Weakness◦Autonomic dysfunction
Peripheral Neuropathic Pain
Other jobs of physician treating patients with peripheral neuropathy◦Manage acute illness if severe◦Give disease-modifying treatment (when
possible)◦Make sure it is not evidence of something
medically important◦Prevent injury
Charcot joint Diabetic foot care/monitoring
◦Manage ataxia◦Manage weakness
Peripheral Neuropathic Pain
Other jobs of physician treating patients with Peripheral neuropathy◦Work up for underlying cause
AAPM&R, AANEM, AAN (England 2010) Highest yield
Fasting glucose, B12, methylmalonic acid +/- homocysteine, SPEP (level C evidence)
If fasting glucose normal, 2 hour GTT Modifications?
Change SPEP to serum immunofixation (SIFE) – more sensitive (Katzmann 2006)
Add HbA1c
Peripheral Neuropathic PainTreatment
◦Considerations – it’s all about adverse effects Severity – does it require treatment? Oral or topical?
Does the distribution of symptoms make topical treatment practical?
If oral meds, which class is best for this patient?
Peripheral Neuropathic PainTreatment
◦Which oral meds are best? Adverse events
Determine eligibility for classes of antineuropathic pain medications
Caution with antidepressant class Duloxetine
Caution with TCA, triptans (seratonin syndrome) Relatively contraindicated in patients with liver
disease, heavy alcohol use, glaucoma (PDR.net 2015)
Tricyclic antidepressants Caution in patients with increased intraocular
pressure, cardiac conditions, urinary retention, siezures (PDR.net 2015)
Peripheral Neuropathic PainTreatment
◦Which meds are best? Adverse events
Determine eligibility for classes of antineuropathic pain medications Caution with anti-epileptic class
Other sedating medications Operating machinery, students, truck
drivers, pilots (PDR.net 2015)
Peripheral Neuropathic PainTreatment
◦Which meds are best? Efficacy
Peripheral Neuropathic Pain
AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)
◦Level A Pregabalin
Peripheral Neuropathic Pain
AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)◦ Level B
Venlafaxine Duloxetine Amitryptiline Gabapentin Valproate Dextramethorphan Morphine sulfate Tramadol Oxycodone controlled-release Capsaicin Isosorbide dinitrate spray Percutaneous electrical nerve stimulation
Peripheral Neuropathic Pain
AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)
◦Level C Lidoderm patch
Peripheral Neuropathic Pain
AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)
◦Level U Topiramate Desipramine Imipramine Fluoxetine Vitamins Alpha-lipoic acid
Peripheral Neuropathic Pain
AAPM&R, AANEM, AAN Consensus statement- Painful diabetic neuropathy (Brill 2011)◦Should not be used (Level B)
Oxcarbazepine Lamotrigine Lacosamide Clonidine Pentoxifylline Mexilitine Electromagnetic field treatment Reiki Low-intensity laser treatment
Peripheral Neuropathic PainConsensus statement from
Canadian Pain Society (Moulin 2014)◦General
Reviewed randomized controlled trials, systematic reviews and existing guidelines
Primary goal is to make pain bearable, not gone – keep reasonable expectations
Peripheral Neuropathic PainConsensus statement from
Canadian Pain Society (Moulin 2014)◦Numbers needed to treat (NNT) for
neuropathies TCA 2.1 Opioids 2.6 Cannabinoids 3.4 Pregabalin 4.5 Tramadol 4.9 Duloxetine 5.1 Capsaicin 0.04% 6.2 Gabapentin 6.5 SSRI 6.8
Peripheral Neuropathic PainConsensus statement from
Canadian Pain Society (Moulin 2014)◦Algorithm
1st line – Gabpentoids, TCA, SNRI 2nd line – tramadol, opioids 3rd line – cannabinoids 4th line – topical lidocaine, methadone,
lamotrigine, lacosamide, tapentadol, botulinum toxin
Peripheral Neuropathic PainConsensus statement from
Canadian Pain Society (Moulin 2014)◦Other considerations
TCA adverse effects – drowsiness, dry mouth, constipation,
urinary retention – caution with elderly Nortryptiline and desipramine better tolerated then
amitrpytiline and imipramine Gabapentoids
Few drug interactions Opioids
Tolerance develops to some side effects but not constipation
Peripheral Neuropathic PainIASP (Finnnerup 2015)
◦Meta-analysis of randomized, double blind studies
◦General principles No evidence of efficacy of specific
medications to specific disorders (possible exception of trigeminal neuralgia)
HIV related neuropathy and radiculopathy may be more refractory than other types of neuropathic pain
Peripheral Neuropathic PainIASP (Finnnerup 2015)
◦NNT (number needed to treat) 50% reduction in pain intensity
NNT NNH Botulinum toxin A 1.9 Tricyclics 3.6 13.4 Tramadol 4.7 12.6 Gabapentin 7.2 (“good”) SNRI 6.4 11.8 Pregabalin 7.7 13.9 Strong opioids 10.6 11.7 Capsaicin 8% 10.6
Peripheral Neuropathic PainIASP (Finnerup 2015)
◦First line Gabapentin (including extended release or encarbil) Pregabalin Duloxetine Venlafaxine XR Tricyclics (caution at high doses)
◦Second line Capsaicin 8% patches Lidocaine patches (low effect size) Tramadol (lower tolerability) Botulinum toxin A SQ (weak evidence) Strong opioids (safety concerns)
Peripheral Neuropathic PainIASP (Finnerup 2015)
◦ Inconclusive recommendations – discrepant findings Combination therapy Capsaicin cream Carbemazapine Topical clonidine Lacosamide Lamotrigine NMDA antagonists Oxcarbazepine SSRI Tapentadol Topiramate Zonisamide
Peripheral Neuropathic PainIASP (Finnerup 2015)
◦Recommendations against use Because of generally negative trials or
safety concerns Weak recommendations against
Cannabinoids Valproate
Strong recommendations against Levetiracetam Mexilitine
Peripheral Neuropathic PainSummary
◦Neuropathic pain is common in neuropathies
◦Pain is one of many aspects of a neuropathy that have to be addressed
◦Consider side effects first when treating neuropathic pain
Peripheral Neuropathic PainThank you!!
Peripheral Neuropathic PainBibliography Bril V, England J, Franklin GM, Backonja M, et al: American Academy of Neurology; American
Association of Neuromuscular and Electrodiagnostic Medicine; American Academy of Physical Medicine and Rehabilitation. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabiliation. PM R. 2011 Apr; 3(4): 345-352.
England JD, Gronseth GS, Franklin G, Carter GT, et al. Practice Parameter: Evaluation of distal symmetric polyneuropathy: Role of laborataory and genetic testing (an evidence-based review): Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology 2009;72:185-192.
Finnerup NB, Attal N, Haroutounian S, McNicol E, et al. Pharmocotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol:2015;162-173.
Katzmann JA, Dispenzieri A, Kyle RA, Snyder MR, et al. Elimination of the need for urine studies in the screening algorithh for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc 2006;81:1575-1578.
Merskey H, Bogduk N. Classification of Chronic Pain. Second edition, IASP Task Force on Taxonomy. “Part III: Pain Terms, A Current List with Definitions and Notes on Usage” pp 209-214. IASP Press, Seattle 1994.
Moulin D, Boulanger A, Clark AJ, Clark H, et al. Pharmocological management of chronic neuropathic pain: revised consensus statement from the Candian Pain Society. . Pain Res Manag. 2014 Nov-Dec;19(6):328-335.
"PDR Search." PDR.Net. 2015. Web. 4 Sept. 2015. Treede RD, Jensen TS, Campbell JN, Cruccu G, et al. Neuropathic pain: Redefinition and a grading
system for clinical and research purposes. Neurology 2008;70: 1630-1635.