Treating neuropathic pain: Congress Berlin 2010
He pointed out to the audience that modern neuropathic pain treatment can be seen to be optimally based on 7 different pillars.
1. Rational pharmacotherapy making use of analgesics which are proven to be effective and safe, such as amitriptyline and pregabaline, titrating slow to avoid dose limiting side effects and combining different analgesics in order to avoid top dosages and the related problems of non adherence to medication.
Treating glia and gliopathic pain
2. Adding new drugs focussing on the newly described drug target of gla. Gla is the main driver of chronic neuropathic pain. During the talk the speaker pointed out that there are various new treatment options to modulate the over active glia, and the example of palmitolethanolamide was described.
Palmitoylethanolamide is a body own fatty acid, developed in Italy and on the market as food for medical purposes ( Normast ) This fatty acid has been documented to be safe and effective in a variety of neuropathic syndromes, such as neuropathic pain in diabetes, carpal tunnel syndrome and sciatic pain. Pilot trials also demonstrated a normalization of decreased nerve velocity in patients suffering from diabetes and carpal tunnel syndrome. Now PEA can also be considered as a breakthrough natural therapy for flu and common colds.
The advantage of palmitoylethanolamide is that no drug-interactions are to be expected and the safety in elderly patients has been documented. Targeting the glia with compounds such as this fatty acid also helps to optimize pain treatment based on classical analgesics. Within the context of multiple modal therapy in neuropathic pain, palmitoylethanolamide is an important new addition to our therapeutic armamentarium.
In our institute we start dosing with micronized palmitoylethanolamide sub lingual for 10 days, and after the initial loading phase we continue with tablets, either 2 times 600 mg or 2 times 300 mg daily, dependent on the response. Meanwhile we have seen positive responses in patients suffering from neuropathic pain due to diabetes, sciatic pain, and neuropathic pain in chronic idiopathic axonal neuropathy and small fibre neuropathy.
EBM based supplements
3. Adding supplements with a clear EBM base such as alpha-lipoic acid. This supplement is in some European countries registered as a drug, such as in Germany, and has been evaluated in many thousands of patients. It’s efficacy and safety has been documented and apart from stomach irritation due to the acidity, the side effect profile is benign. We always prescribe the R- alpha- lipoic acid in the dose range of 300-600 mg daily in 3 different gifts.
4. Adding topical formulations of analgesics, such as amitriptyline, gabapentine, or baclofen. All these creams have been evaluate in small trials and we have optimized formulation and concentration based on the continuous feedback we receive from our patients. For instance, most patients experience a quick pain relief within 30 minutes after 5 or 10% cream, and they mostly use an amount between 1 to 3 gram of cream for each foot. The topical cream has two mechanism of action, it helps a slow and steady penetration through the skin, and thus acts as a controlled release formulation, avoiding peak dose effects and non adherence. And it has a local effect, probably by direct effects on the unmeyelinated painfibres in the skin.
Diet, exercise and physiotherapy
5. Diet, exercise and physiotherapy. For patients suffering from chronic neuropathy it is important to create an exercise programme in order to train compensatory muscle groups, muscle power, stability and balance, and enhance condition in order to prevent falls.
PENS and TENS
6. Pain modulation therapies such as TENS and PENS. These treatment modalities make use of low impact electric currents applied either via surface electrodes, such as in TENS, or via the Percutaneus Electrical Nerve Stimulation technique applying electricity via thin needle electrodes through the skin.
Coaching: partnership with the patient
7. Coaching: it is extremely important to coach patients to become active as their own case managers, and help them to change behavior such as inactivity and immobility into proactivity and movement. Bringing the body in movement is counterintuitive for many patients suffering from chronic pain, but data clearly supports physical and mental activity in order to decrease chances for depressive mood and feelings and catastrophizing thinking.
Based on this regime many patients suffering from neuropathic pain have been succesfully treated, patients with neuropathic pain due to diabetes, due to chemotherapy ( cisplatin ) and neuropathic pain in chronic idiopathic axonal neuropathy and small fibre neuropathy.
J.M. Keppel Hesselink, D.J. Kopsky. An integrative approach for the treatment of neuropathic pain. EU J Int Med 2010; 2 (4): 190