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Referencias: Lumbalgia crónica con componente neuropático


Attal N, Cruccu G, Baron R, et al. EFNS guidelines onthe pharmacological treatment of neuropathic pain: 2010revision. Eur J Neurol.

Background and objectives: This second European Federation of Neurological Societies Task Force aimed at updating the existing evidence about the pharmacological treatment of neuropathic pain since 2005. Methods: Studies were identified using the Cochrane Database and Medline. Trials were classified according to the aetiological condition. All class I and II randomized controlled trials (RCTs) were assessed; lower class studies were considered only in conditions that had no top-level studies. Treatments administered using repeated or single administrations were considered, provided they are feasible in an outpatient setting. Results: Most large RCTs included patients with diabetic polyneuropathies and postherpetic neuralgia, while an increasing number of smaller studies explored other conditions. Drugs generally have similar efficacy in various conditions, except in trigeminal neuralgia, chronic radiculopathy and HIV neuropathy, with level A evidence in support of tricyclic antidepressants (TCA), pregabalin, gabapentin, tramadol and opioids (in various conditions), duloxetine, venlafaxine, topical lidocaine and capsaicin patches (in restricted conditions). Combination therapy appears useful for TCAgabapentin and gabapentin-opioids (level A). Conclusions: There are still too few large-scale comparative studies. For future trials, we recommend to assess comorbidities, quality of life, symptoms and signs with standardized tools and attempt to better define responder profiles to specific drug treatments.



Bennett IM, Attal N, Backonja MM, et al. Using screening tools to identify neuropathic pain. Pain. 2007;127:199-203.

It is widely accepted that the unique painful and non-painful sensations in neuropathic pain are the result of particular mechanisms, and that specific management strategies for neuropathic pain should be applied to tackle them. Ideally, the treatment of chronic pain should be directed at eliminating the cause of pain, but in reality this is rarely possible. The management of chronic pain is therefore often limited to reducing the intensity of such pain and associated symptoms. Pain is essentially a subjective phenomenon described with patient-specific symptoms and expressed with a certain intensity. It therefore makes sense to examine the value of verbal descriptors and pain qualities as a basis for distinguishing neuropathic pain from other types of chronic pain. Work by Dubuisson and Melzack (1976) and later by Boureau et al. (1990) supported anecdotal opinion that key words might be discriminatory for neuropathic pain. In the last 5 years, much research has been undertaken to develop screening tools for this purpose. These tools are based on verbal pain description with, or without, limited bedside testing. This paper reviews the strengths and weaknesses of such tools.



Blanco E, Gálvez R. Prevalencia del dolor neuropático (DN), según DN4, en atención primaria. Semergen. 2012;38(4):203-210.

Background: Primary Care Physicians are usually the first to see patients with neuropathic pain. The aim of this study is to assess the prevalence of neuropathic pain, its therapeutic management, and to clinically characterize these patients. Material and methods: An epidemiological, observational, cross-sectional study was carried out in Spanish Primary Care settings. The first 25 patients older than 18 years with any type of pain (a total of 16,115) were registered, and the first 5 with a high neuropathic pain component according to the NP4 test, and was clinically confirmed (n= 3,836) were included in the study. Pain intensity and impact on daily activities, as well as overall satisfaction with treatment were assessed. Results: A total of 45.7% of patients had neuropathic pain according to NP4 test. The median age was 59 years, and 60% were women. Patients took a mean of 2.4 drugs, with NSAIDs (53%) and non-opioid analgesics (51%) being the most common. The scores for Pain intensity and interference in daily activities were both 6.2. The overall opinion of the SATMED-Q test was 47.3/100, which was 1.4 points lower than the standardised score according to Spanish population. Conclusions: Neuropathic pain according to NP4 test is highly prevalent in Spanish Primary Care settings. The management of these patients with NSAIDs and non-opioid analgesics is not appropriate, as they are not recommended for this kind of pain. Although they were being treated with more than 2 analgesics, they still referred to high pain intensity, interference in daily activities, and a low general opinion of the treatment.



Blanco E, Galvez R. Effectiveness of pregabalin as monotherapy or combination therapy for neuropathic pain in patients unresponsive to previous treatment in a Spanish primary care setting. Clin Drug Investig. 2013;33:633-645.

Background and Objective Patients from a previous study of neuropathic pain (NP) in the Spanish primary care setting still had symptoms despite treatment. Subsequently, patients were treated as prescribed by their physician and followed up for 3 months. Since pregabalin has been shown to be effective in NP, including refractory cases, the objective of this study was to assess the effectiveness of pregabalin therapy in patients with NP refractory to previous treatments. Methods This was a post hoc analysis of pregabalin-naïve NP patients treated with pregabalin in a 3-month follow-up observational multicenter study to assess symptoms and satisfaction with treatment. Patients were evaluated with the Douleur Neuropathique en 4 questions (DN4), the Brief Pain Inventory (BPI) and the Treatment Satisfaction for Medication Questionnaire (SATMED-Q) overall satisfaction domain. Results 1,670 patients (mean age 58 years, 59 % women), previously untreated or treated with C1 drug other than pregabalin, were treated with pregabalin (37 % on monotherapy). At 3 months, pain intensity and its interference with activities decreased by half (p<0.0001), while the number of days with no or mild pain increased by a mean of 4.5 days (p<0.0001). Treatment satisfaction increased twofold (p<0.0001). Patients with a shorter history of pain and those with neuralgia and peripheral nerve compression syndrome (PCS) as etiologies had the highest proportion on monotherapy and showed the greatest improvements in pain-related parameters in their respective group categories. Conclusion Treatment with pregabalin (as monotherapy or combination therapy) provides benefits in pain and treatment satisfaction in patients with NP, including refractory cases. Shorter disease progression and neuralgia and PCS etiologies are favorable factors for pregabalin treatment response.



Bohlega S, Alsaadi T, Amir A, et al. Guidelines for the pharmacological treatment of peripheral neuropathic pain: expert panel recommendations for the Middle East region. J Int Med Res. 2010;38(2):295-317.

Neuropathic pain (NeP) has been the focus of extensive basic and clinical research over the past 20 years. This has led to an increased understanding of underlying pathophysiological mechanisms and the development of new therapeutic agents, as well as a clearer definition of the role of established medications. To date there are no published treatment guidelines for NeP in the Middle East. A multidisciplinary panel of Middle East and international experts met to review critically and reach a consensus on how best to apply evidencebased guidelines for the treatment of NeP (mainly peripheral NeP) in the Middle East. The expert panel recommended pregabalin, gabapentin and secondary amine tricyclic antidepressants (nortriptyline and desipramine) as first-line treatments for peripheral NeP. Serotonin–norepinephrine reuptake inhibitor antidepressants, tramadol and controlled-release opioid analgesics were recommended as second-line treatments. There is a need to increase diagnostic awareness of NeP, use validated screening questionnaires and undertake more treatment research in the Middle East region.



Freynhagen R, Baron R. The evaluation of neuropathic components in low back pain. Curr Pain Headache Rep. 2009;13(3):185-190.

Chronic low back pain is highly prevalent in Western societies. Large epidemiological studies show that 20% to 35% of patients with back pain suffer from a neuropathic pain component. Presently, chronic lumbar radicular pain is the most common neuropathic pain syndrome. The pathophysiology of back pain is complex and nociceptive, and neuropathic pain–generating mechanisms are thought to be involved, which established the term mixed pain syndrome. Neuropathic pain may be caused by lesions of nociceptive sprouts within the degenerated disc (local neuropathic), mechanical compression of the nerve root (mechanical neuropathic root pain), or by action of infl ammatory mediators (inflammatory neuropathic root pain) originating from the degenerative disc even without any mechanical compression. Its diagnosis and management remain an enigma, mainly because there is no gold standard for either. Accuracy of diagnostic tests used to identify the source of back pain and their usefulness in clinical practice, particularly for guiding treatment selection, is unclear. In connection with the specific instance of back pain (one of the single most costly disorders in many industrialized nations), neuropathic pain components are a significant cost factor.



Freynhagen R, Serpell M, Emir B, et al. A comprehensive drug safety evaluation of pregabalin in peripheral neuropathic pain. Pain Pract. 2013 Nov 27.doi:10.1111/papr.12146.

Pregabalin is a commonly used therapy currently recommended as first-line treatment for a number of neuropathic pain (NeP) conditions. Since licensure, a number of clinical trials of pregabalin in different NeP conditions have been completed from which additional data on safety and tolerability can be drawn. In this analysis, patient-level data from 31 randomized clinical trials of pregabalin in peripheral NeP sponsored by Pfizer were pooled and assessed for incidence of adverse events (AEs). Incidence by age, disease condition, and race, together with risk differences and time to onset and resolution of AEs, was assessed. In total, 7,510 patients were included: 4,884 on pregabalin (representing 805 patient-years treatment) and 2,626 on placebo. Pregabalin vs. placebo risk analysis identified 9 AEs with a risk difference, for which the lower limit of the 95% confidence interval (CI) was > 1%: dizziness (risk difference [95% CI]: (17.0 [15.4 to 18.6]), somnolence (10.8 [9.5 to 12.1]), peripheral edema (5.4 [4.3 to 6.4]), weight increase (4.7 [3.9 to 5.5]), dry mouth (2.9 [2.1 to 3.8]), constipation (2.3 [1.5 to 3.2]), blurred vision (2.2 [1.6 to 2.9]), balance disorder (2.0 [1.5 to 2.5]), and euphoric mood (1.6 [1.2 to 2.0]). The most common AEs, dizziness and somnolence, typically emerged within the first 1 to 2 weeks of treatment and resolved 1 to 2 weeks later, without resulting in cessation of treatment. The data from this review provide information, indicating which AEs may be expected in patients treated with pregabalin, and suggest that careful dose titration to the highest tolerable dose is the most appropriate approach in clinical practice.



Garcia Joao B.S, Prevalence of Low Back Pain in Latin America: A Systematic Literature Review Pain Physician 2014; 17:379-391 • ISSN 1533-3159

Background: Chronic low back pain is considered as a high-impact condition that affects the working population of Latin America, with long reaching social and economic repercussions. Its true frequency is unknown due to the absence of well-designed clinical trials that use standardized definitions and criteria. Objectives: To evaluate the prevalence of chronic non-specific low back pain among the Latin American population. Study Design: A systematic review of chronic non-specific low back pain in Latin America. Setting: Meeting of Change Pain Latin America, Mexico. Methods: Data sources included relevant literature identified through searches of published studies between August 30, 2002, and August 30, 2012, in 7 electronic databases: Cochrane BVS, Pubmed, Medline, Lilacs, Scielo, Hinari, and MedCarib. Publications dealing with low back pain of a posttraumatic, infectious, or malignant origin were excluded. Two reviewers selected in an independent manner all eligible studies using the MOOSE checklist and extracted data on both prevalence and risk factors associated with low back pain. A narrative synthesis of the results was drafted, which was later validated by a panel of clinical experts on pain. Results: Twenty-eight studies were included in the review, comprising a total of 20,559 subjects from 7 countries in the region. Four of these studies, with significant methodological differences between them, measured the frequency of chronic low back pain with results that varied from 4.2% to 10.1%. Four studies are part of the Community Oriented Program for Control of Rheumatic Diseases (COPCORD) program reports, and were pooled and analyzed separately because of their particular design. Their prevalence estimations varied between 1.8% and 11.3%. The remaining 20studies evaluated a total population of 6,992 subjects, and found a prevalence of low back pain of 31.3%. Based on an epidemiological model constructed on both times to resolution and low back pain recurrence rates, the prevalence of chronic low back pain in Latin America was estimated to be around 10.5%. Some risk factors reported by the authors are long working hours with the worker in the sitting position, obesity and overweight, pregnancy, smoking, advanced age, lifting and carrying heavy loads, domestic work, sedentary lifestyles, and duration of current employment. A subgroup analysis of the population under study yielded an estimated prevalence of low back pain of 16.7% for the population exposed to a lower number of risk factors and 65% for the higher risk subgroup. In this review, we made an exhaustive search of studies evaluating the epidemiology of chronic low back pain in the Latin America region. Limitations: The large topographic and chronologic variability in definitions of low back pain, interviewer bias, and subject selection bias. Conclusions: Despite the sparse information and the methodological heterogeneity of the studies, pooled results allowed for an indirect estimation of the prevalence of low back pain in the region that was pretty consistent with the published results obtained from other settings. New studies need to be carried out to supplement and overcome the methodological weaknesses of those previously conducted. Key words: Prevalence, epidemiology, low back pain, Latin America, chronic pain



Golob, Anna L, Low Back Pain, Med Clin N Am 98 (2014) 405–428

Low back pain is a common, frequently recurring condition that often has a nonspecific cause. History and physical examination should focus on evaluation for evidence of systemic or pathologic causes. Imaging is only indicated when there is evidence of neurologic deficits or red flags to suggest fracture, malignancy, infection, or other systemic disease, or when symptoms do not improve after 4 to 6 weeks. Most nonspecific low back pain will improve within several weeks with or without treatment. Back pain that radiates to the lower extremities, occurs episodically with walking or standing erect, and is relieved by sitting or forward spine flexion is typical of neuroclaudication and suggests central spinal stenosis. All patients with acute or chronic low back pain should be advised to remain active. The treatment of chronic nonspecific low back pain involves a multidisciplinary approach targeted at preserving function and preventing disability. Urgent surgical referral is indicated in the presence of severe.



R. C. W. Jones III & Miroslav “Misha” Backonja, Review of Neuropathic Pain Screening and Assessment Tools, (2013) DOI 10.1007/s11916-013-0363-6

Chronic pain due to injury to or diseases of the nervous system, known as neuropathic pain (NP), is a common debilitating medication condition for which there are currently several symptomatically effective therapies. Therefore, early identification of NP in the primary and specialty care setting will avoid unnecessary delays in amelioration of symptoms. Given that it is associated with unique symptoms and physical exam signs, several assessment tools have been developed to aid medical practitioners in the identification of patients with NP. The majority of these tools have been developed to differentiate NP from nonNP and to quantify the severity of symptoms that define NP, and some have been used to aid in assessment of response to interventions. This focused review will describe the primary NP assessment tools that are currently available, and discuss their suitability for screening patients and for research applications. Wider use of NP assessment tools will facilitate the development of new therapies, further clarify the epidemiology of this condition,and improve the treatment of NP.



Kaki AM, El-Yaski AZ. Identifying neuropathic pain among patients with chronic low-back pain: use of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale. Reg Anesth Pain Med. 2005;30(5):422-428.

Background and Objectives: Although the literature contains information about prevalence and incidence of low-back pain (LBP), little information is available about the contribution of the neuropathic element to LBP. Our study was designed to investigate the prevalence of neuropathic pain among a sample of chronic LBP patients in Saudi Arabia by use of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale.
Methods: A total of 1,169 patients from 117 centers agreed to participate in the study over a period of 6.5 months. The LANSS pain scale was applied to each patient in an interview format. The characteristics of pain and sensory dysfunction were tested and recorded.
Results: According to the LANSS pain scale, 639 patients (54.7%) had scores of 12 points or more, which suggested a neuropathic type of pain, and 530 patients (45.3%) had scores of less than 12, which suggested a nociceptive type of pain. Factors that are associated with neuropathic pain are advanced age, female gender, increased height, white race, hypertension and diabetes, a history of smoking, previous back surgery, and previous medications.
Conclusion: Neuropathic pain is a major contributor to chronic LBP, and the LANSS pain scale is a useful tool to distinguish patients with neuropathic pain from those with nociceptive pain.



Kavoussi Richard, Pregabalin: From molecule to medicine, European Neuropsychopharmacology (2006) 16, S128–S133

Pregabalin, a compound with a novel mechanism of action (MOA), has demonstrated efficacy as an adjunctive treatment for epilepsy and in several neuropathic pain models. Multiple generalized anxiety disorder (GAD) clinical trials have shown that pregabalin has efficacy similar to the benzodiazepines and venlafaxine. Onset of anxiolytic effect was observed as early as Week 1 of treatment, and efficacy was seen in treating both psychic and somatic anxiety symptoms. Pregabalin binds potently and selectively to the alpha-2-delta subunit of “hyper-excited” voltage-gated calcium channels (VGCCs). The binding of pregabalin to VGCCs changes their conformation, reducing calcium influx at nerve terminals. Pregabalin only modulates the release of excitatory neurotransmitters in “hyper-excited” neurons, restoring them to normal physiological state. This newly defined MOA is believed to confer on pregabalin its anxiolytic, analgesic, and anticonvulsant properties. Thus, pregabalin may offer physicians an effective and well-tolerated therapy for GAD, which differs from existing treatments.© 2006 Published by Elsevier B.V.



Morlion B. Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components. Curr Med Res Opin. 2011;27(1):11-33.

Aim:To review pharmacological management of chronic low back pain (LBP), with respect to management of nociceptive and neuropathic components.Methods: Studies were identified by a PubMed search of English-language papers from the last 10 years, with additional hand searches of relevant reviews. Discussion: Paracetamol, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors target the nociceptive component of chronic LBP, and do not affect neuropathic pain mechanisms. Antidepressants target the neuropathic component of chronic LBP; however, conflicting efficacy results have been reported. Opioids target both nociceptive and to a lesser extent neuropathic pain. They are effective in chronic LBP, but many patients require higher doses or combination treatment. The long-term efficacy of opioids in chronic LBP has been questioned because of the absence of high-quality data and concerns regarding tolerability and dependence. The topical preparation lidocaine 5% plaster, indicated in post-herpetic neuralgia, is effective in localized neuropathic pain in patients with chronic LBP. Pregabalin is ineffective as monotherapy for chronic LBP but is effective when combined with celecoxib or opioids. Muscle relaxant monotherapy is ineffective in chronic LBP. Combination therapy is often necessary in patients with chronic LBP, in order to manage both nociceptive and neuropathic pain components. Conclusion: Chronic LBP often comprises both nociceptive and neuropathic components, therefore a multimodal and individualized treatment approach is necessary. Combining drugs with different mechanisms of action (e.g. an agent with m-receptor activity plus an agent of a different class) represents a rational approach to management of chronic LBP with both nociceptive and neuropathic components.


 

Patrick Nathan, Acute and Chronic Low Back Pain, Med Clin N Am 98 (2014) 777–789
 
Numerous factors put patients at risk for the development of chronic back pain, including age, educational status, psychosocial factors, occupational factors, and obesity. Evaluation of patients with back pain includes completing an appropriate history (including red-flag symptoms), performing a comprehensive physical examination, and, in some scenarios, obtaining imaging in the form of plain radiographs and magnetic resonance imaging. Treatment of an acute episode of back pain includes relative rest, activity modification, nonsteroidal anti-inflammatories, and physical therapy. Patient education is also imperative, as these patients are at risk for further episodes of back pain in the future. Chronic back pain (>6 months’ duration) develops in a small percentage of patients. Clinicians. Ability to diagnose the exact pathologic source of these symptoms is severely limited, making a cure unlikely. Treatment of these patients should be supportive, the goal being to improve pain and function rather than to “cure” the patient’s condition.
 

 


Saldaña M, Navarro A. Patient-reported-outcomes in subjects with painful lumbar of cervical radiculopathy treated with pregabalin: evidence from medical practice in pramary care settings. Rheumatol Int. 2010;30(8):1005-1015.

Abstract. The objective of this study was to evaluate the effect of pregabalin in painful cervical or lumbosacral radiculopathy treated in Primary Care settings under routine clinical practice. An observational, prospective 12-week secondary analysis was carried-out. Male and female above 18 years, naïve to PGB, with refractory chronic pain secondary to cervical/lumbosacral radiculopathy were enrolled. SF-MPQ, Sheehan Disability Inventory, MOS Sleep Scale, Hospital Anxiety and Depression Scale and the EQ-5D were administered. A total of 490 (34%) patients were prescribed PGB-monotherapy, 702 (48%) received PGB add-on, and 159 (11%) were administered non-PGB drugs. After 12 weeks, significant improvements in pain, associated symptoms of anxiety, depression and sleep disturbances, general health; and level of disability were observed in the three groups, being signifficantly greater in PGB groups. In routine medical practice, monotherapy or add-on pregabalin is associated with substantial pain alleviation and associated symptoms improvements in painful cervical or lumbosacral radiculopathy.



Toelle TR, Varvara R. Pregabalin in neuropathic pain related to DPN, cancer and back pain: analysis of a 6-week observational study. Open Pain J. 2012;5:1-11.

Abstract: Background: Neuropathic pain is associated with many conditions. Pregabalin has demonstrated efficacy in randomized, controlled trials (RCTs) in peripheral and central neuropathic pain. Observational studies complement findings from RCTs by enabling an agent to be studied in real-world patients and circumstances.
Methods: Patients with neuropathic pain were treated with pregabalin 150-600 mg/day in this 6 week observational study. Analyses of subsets of patients with painful diabetic peripheral neuropathy (DPN; n=4633), back pain with a neuropathic component (n=3800), and cancer-related neuropathic pain (n=345) were undertaken.
Results: The mean pregabalin doses ranged from 219 to 250 mg/day across the disease groups. Mean baseline pain scores (6.4 to 7.0 across the three disease states) indicated patients had moderate to severe pain. Pregabalin was associated with a rapid and significant reduction in pain from week 1 to endpoint in all groups. Over 80% in each of the groups had a ≥30% pain reduction in their pain at 6 weeks, and over two-thirds had a ≥50% reduction. Pain-related sleep interference decreased rapidly and significantly. Most patients (87%) were either very satisfied or satisfied with the action of pregabalin. General well-being improved significantly over the 6 weeks. Pregabalin was generally well tolerated; the most common adverse event overall was dizziness (1.4%). Few patients (≤6.1%/group) discontinued due to adverse events.
Conclusions: In neuropathic pain patients in day-to-day practice, pregabalin was associated with notable reductions in pain and sleep interference. The benefits of pregabalin were reflected in the high level of patient satisfaction and improvement in general well-being.



Toth Cory, Pregabalin: latest safety evidence and clinical implications for the management of neuropathic pain, Ther Adv Drug Saf 2014, Vol. 5(1) 38–56 DOI: 10.1177/2042098613505614

Used mainly for the management of neuropathic pain, pregabalin is a gabapentinoid or anticonvulsant that was initially developed as an antiepileptic agent. After more than a decade of experience with pregabalin, experience and studies have shown that the adverse effect profile of pregabalin is well tolerated for the management of neuropathic pain and other conditions. Its use is associated with benign central nervous system and systemic adverse effects, and there are very limited metabolic, idiosyncratic or known teratogenic adverse effects. Along with its efficacy in particular neuropathic pain conditions, pregabalin’s safety led it to be one of the first pharmacotherapies considered for the management of neuropathic pain. This review discusses the use of pregabalin as well as its potential adverse effects, including the most commonly noted features of sedation, dizziness, peripheral edema and dry mouth. Although other adverse effects may occur, these appear to be uncommon. The review also discusses the clinical implications of pregabalin’s use for the clinician.



Wellford Robert Carter, Managing Neuropathic Pain, Med Clin N Am - (2015)

Neuropathic pain (NP) arises from injuries or diseases affecting the somatosensory component of the nervous system at any level of the peripheral nervous system or central nervous system (CNS). Regardless of location of injury, NP is diagnosed based on common neurologic signs and symptoms that are revealed by history taking and on physical examination. NP is best treated with a combination of multiple therapeutic approaches, which starts with patient education, and the treatments include conservative, complementary, medical, interventional, and surgical treatment modalities. Goals of treatment are the same as in pain management in general, and they include improvement in pain control and in coping skills as well as restoration of functional status. Early identification of realistic treatment expectations is the key to building a successful relationship with a patient suffering from NP. In most instances when treating chronic NP, the approach to pain management begins with conservative therapies and advances to more interventional ones only when earlier modalities do not meet goals of pain relief and improved function, because risks increase with the invasiveness of the therapies. Most patients with NP benefit most from an individualized, multimodal approach that emphasizes both pain and function.

Código Interno: PP-LYR-PEB-0027

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