DOCSLIB.ORG

Current and Evolving Standards of Care for Patients with Neuropathic Pain Southern Pain Society 2020

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Current and Evolving Standards of Care for Patients with Neuropathic Pain Southern Pain Society 2020 Current and Evolving Standards of Care For Patients with Neuropathic Pain Southern Pain Society 2020 Miroslav Backonja, MD Department of Anesthesiology and Pain Medicine Department of Neurology University of Washington – Seattle Objectives • Definition of neuropathic pain (NP) and its implications • Application of new assessment approaches to NP and their implications for treatment • An example of diabetic neuropathy pain to demonstrate challenges in assessing and treating NP • Standards and practice of NP treatment • Developments in treatment of NP Neuropathic Pain Pain caused by a lesion or disease of the somatosensory nervous system. Treede et al. Neurology 2008 Jensen et al Pain 2011 https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698 1 Neuropathic Pain Pain caused by a lesion or disease of the somatosensory nervous system. Central Sensitization Treede et al. Neurology 2008 Jensen et al Pain 2011 Peripheral Sensitization https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698 Neuropathic Pain – Implications of definition - It is necessary to perform neurological somatosensory exam across the range of fiber types, including small fibers (e.g. such as test for cold and hot) to establish the diagnosis of neuropathic pain - NP is a positive and confirmatory diagnosis, not diagnosis of exclusion -In NP, history and neurological sensory exam reveal a mix of positive phenomena (e.g. allodynia) and negative (e.g. deficits) phenomena across the range of sensory modalities Question for the audience: • By raising your hands, please indicate as Yes: Are you sufficiently well trained to perform neurological sensory examination across all modalities which would allow you to make with confidence diagnosis of neuropathic pain and its severity? 2 Pain Mechanisms as the Basis for the Multi-Modal Neuropathic Pain Therapy Perception Endogenous Modulation Cognitive behavioral approaches Norepinephrine Serotonin Endogenous opiates Endocannabinoids Descending Inhibition TCAs: nortriptyline SNRIs: duloxetine Opioids: morphine, tramadol Transduction Synaptic Transmission TRPV1:Capsaicin a-2-d Ca++ : GBP,PGB NMDAr: ketamine Periph. Transmission Opioids: morphine, tramadol Na+: Lidocaine, TCA Ca++: ziconotide Revised after: Beydoun A, Backonja M. J Pain Symptom Manage.2003. Third mechanistic pain term Nociplastic pain (2016) Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain. • Note: Patients can have a combination of nociceptive and nociplastic pain • Commentary: Nociplatic pain is now interchangeably used to mean central sensitization or what is also called centralized pain, all of which is frequently confused and differentiated from central neuropathic pain Interpreting NP in context of total patient In patients with chronic pain, NP is more then likely that NP is one of a few types of pain; most often associated is myofascial pain 3 Comparison of NP Symptoms Discrimination Tools Bennett M et al, Pain 2007 Types of Pain in PHN Implication When examining patient where working diagnosis is Neuropathic Pain, anticipate a mix of positive and negativesigns. Baron et al Lancet Neuro 2010 Fosterpointer et al Pain 2018 Stratifying patients with peripheral neuropathic pain based on sensory profiles J. Vollert et al.·158 (2017) 1446–1455 4 Controlled Pain Modulation - CPM • Utilizes principles of descending modulation • Rating of one stimulus is affected by another noxious stimulus • Example of CPM predicting response of response to Duloxetine among patients with Painful Diabetic Neuropathy Yarnitsky et al 2010, 2012, 2013 The effect of oxcarbazepine in peripheral neuropathic pain depends on pain phenotype D.T. Demant et al. / PAIN 155 (2014) 2263–2273 Patients with peripheral neuropathic pain: polyneuropathy, surgical or traumatic nerve injury, or PHN 83 patients: 31 irritable nocicipetor by QST and 52 nonirritable nociceptor phenotype NNT - > 50% pain relief: 6.9 (95% CI 4.2-22) in the total sample, 3.9 (2.3-12) in the irritable, and 13 (5.3-100) in the nonirritable nociceptor phenotype Case Study: VAMC in Madison WI Little NP Tool that Could Setting: Primary Care Clinics (residents, fellows, NP’s, PA’s) Challenge: too many opioids, too many frustrated patients and providers Opportunity: intervention to improve pain assessment • MA notices pain rating > 4/10 on intake => administer ID Pain • IDPain > 2/6 => flag to provider that pain is probably Neuropathic • Provider performs standardized sensory exam => confirm DX • Order labs: BS, HgbA1c, TFTs, B12, folate • Consider further work-up as indicated • Prescribe: GBP, TCA*, Outcome: Improved care, less frustration 5 Case Study: VAMC in Madison WI Little NP Tool that Could Setting: Primary Care Clinics (residents, fellows, NP’s, PA’s) Challenge: too many opioids, too many frustrated patients and providers Opportunity: intervention to improve pain assessment • MA notices pain rating > 4/10 on intake => administer IDPain • IDPain > 2/6 => flag to provider that pain is probablyNeuropathic • Provider performs standardized sensory exam => confirmDX • Order labs: BS, HgbA1c, TFTs, B12, folate • Consider further work-up as indicated • Prescribe: GBP, TCA*, Outcome: Improved care, less frustration Beyond Nervous System: Immune, MSK, GI, endocrene …. Beyond Physiology: gender, genetics, environment …. Integrative Pain Medicine, including care of patients with NP, guides us to look at the whole patient in their environment Types of Therapies for Neuropathic Pain Disease modifying * None available at the present Symptomatic * Pharmacological neuromodulation • topical • systemic • intrathecal * Electrical neuromodulation and neuroablation * Behavioral therapies and interventions 6 Principles of Pharmacotherapy • Assessment of pain and associated symptoms – implications for treatment planning: • Constant ongoing pain => scheduled meds • Pain flares => non-medication approaches • Associated comorbidities => specific therapies Painful Diabetic Neuropathy Age 20 years or older: 30.2 million people (12.2%) of the U.S. population have diabetes, report 2017 http://www.cdc.gov/diabetes/pubs/statsreport17/national-diabetes-report-web.pdf 60-70% has neuropathy 15-31 % have neuropathic pain symptoms (PDN) PDN estimated at > 2,500,000 National Diabetes Statistics Report Pathophysiology Diabetic Neuropathy (DN) Hyperglycemia - central to all pathogenic process Impaired structure - axons, myelin and other supporting elements Impaired repair and regenerative mechanisms Hypoxia - microvascular insufficiency Pathogenesis of pain in DN (PDN) Increase of alpha-adrenoceptors mRNA in DRG’s Impaired Na+ channel function (e.g. Nav1.7) Spinal mechanisms - loss of inhibition Supraspinal factors - not well studied, probably important Said G Nat Clin Pract Neurol 2007 Tefsay et al, Diab Met Res Rev 2012 Urban et al, Exp Neuro 2012 7 Diabetic Peripheral Neuropathy (DPN): A Heterogeneous Disorder Symptoms depend on types of nerve fibers involved Sensory fibers => Altered sensory function Pain, numbness, loss of proprioception Autonomic fibers => Loss of function Digestive, urogenital, cardiovascular, sudomotor Motor fibers => Muscle weakness Types of Diabetic Neuropathy and its Distribution with Associated Neuropathic Pain 1. radiculitis 2. entrapment 3. plexopathy 4. distal polyneuropathy 5. mononeuritis multiplex Therapies Proven in Randomized Clinical Trials to be Effective in Relieving Pain of DPN Centrally-acting Treatments Peripherally-acting Treatments Antidepressants Topical analgesics TCAs, Duloxetine* (SNRI) Capsaicin* Lidocaine Anticonvulsants Gabapentin, Pregabalin* Vasodilators Isosorbide dinitrate Opioid analgesics Complementary Alternative Tapentadol* Medicine Spinal cord stimulation Alpha lipoic acid (PO, IV) * Therapies currently FDA-approved in the US for the treatment of pain of DPN 8 Is there a way to predict those patients likely to respond to a drug? Conditioned Pain Modulation (CPM): - Activates descending inhibition - Patients with NP have impaired CPM - Example: patients with DPN who have impaired CPM preferentially respond to duloxetine Yarnitsky et al Pain 2012 Finnerup N et al Lancet Neurol 2015 Finnerup N et al Lancet Neurol 2015 Strong recommendations for use First Line Therapy Gabapentin 1200–3600 mg, in three divideddoses Gabapentin ER 1200–3600 mg, in two divideddoses Pregabalin 300–600 mg, in two divideddoses Duloxetine 60–120 mg, once a day TCAs 25–150 mg, once a day 9 Finnerup N et al Lancet Neurol 2015 Weak recommendations for use Second line therapy Capsaicin 8% patches* 1-4 patches to the painful area for 30-60 min every 3 mo Lidocaine patches* 1-3 patches to the region of pain once a day, up to 12h Tramadol 200–400 mg, in two (tramadol ER) or three divideddoses Third line therapy Strong opioids Individual titration *peripheral neuropathic pain Finnerup N et al Lancet Neurol 2015 Panel: Drugs or drug classes with inconclusive recommendations for use or recommendations against use based on the GRADE classification Inconclusive recommendations Weak recommendations against use • Combination therapy • Cannabinoids • Capsaicin cream • Valproate • Carbamazepine • Clonidine topical • Lacosamide Strong recommendations against use • Lamotrigine • Levetiracetam • NMDA antagonists • Mexiletine • Oxcarbazepine • SSRI antidepressants • Tapentadol • Topiramate • Zonisamide Patient Assisted Intervention for Neuropathy:
Load more

Recommended publications
  • Could Mycolactone Inspire New Potent Analgesics? Perspectives and Pitfalls
    toxins Review Could Mycolactone Inspire New Potent Analgesics? Perspectives and Pitfalls 1 2 3, 4, , Marie-Line Reynaert , Denis Dupoiron , Edouard Yeramian y, Laurent Marsollier * y and 1, , Priscille Brodin * y 1 France Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR8204-CIIL-Center for Infection and Immunity of Lille, F-59000 Lille, France 2 Institut de Cancérologie de l’Ouest Paul Papin, 15 rue André Boquel-49055 Angers, France 3 Unité de Microbiologie Structurale, Institut Pasteur, CNRS, Univ. Paris, F-75015 Paris, France 4 Equipe ATIP AVENIR, CRCINA, INSERM, Univ. Nantes, Univ. Angers, 4 rue Larrey, F-49933 Angers, France * Correspondence: [email protected] (L.M.); [email protected] (P.B.) These three authors contribute equally to this work. y Received: 29 June 2019; Accepted: 3 September 2019; Published: 4 September 2019 Abstract: Pain currently represents the most common symptom for which medical attention is sought by patients. The available treatments have limited effectiveness and significant side-effects. In addition, most often, the duration of analgesia is short. Today, the handling of pain remains a major challenge. One promising alternative for the discovery of novel potent analgesics is to take inspiration from Mother Nature; in this context, the detailed investigation of the intriguing analgesia implemented in Buruli ulcer, an infectious disease caused by the bacterium Mycobacterium ulcerans and characterized by painless ulcerative lesions, seems particularly promising. More precisely, in this disease, the painless skin ulcers are caused by mycolactone, a polyketide lactone exotoxin. In fact, mycolactone exerts a wide range of effects on the host, besides being responsible for analgesia, as it has been shown notably to modulate the immune response or to provoke apoptosis.
    [Show full text]
  • Ketamine: an Update for Its Use in Complex Regional Pain Syndrome
    xperim & E en l ta a l ic P in h Bentley et al., Clin Exp Pharmacol 2015, 5:2 l a C r m f Journal of DOI: 10.4172/2161-1459.1000169 o a l c a o n l o r g u y o J ISSN: 2161-1459 Clinical and Experimental Pharmacology Commentry Open Access Ketamine: An Update for Its Use in Complex Regional Pain Syndrome and Major Depressive Disorder William E Bentley*, Michael Sabia, Michael E Goldberg and Irving W Wainer Cooper University Hospital, Camden, New Jersey, United States of America Abstract In recent years, there has been significant research in regard to the efficacy of ketamine in regards to treating Complex Regional Pain Syndrome (CRPS) and Major Depressive Disorder (MDD). Many patients have had substantial symptomatic relief; however, not all patients have had positive results. This has prompted current research with evidence to suggest certain biomarkers exist that would infer which patients will/will not respond to ketamine treatment. Current biomarkers of interest include D-Serine (D-Ser) and magnesium, which will be discussed. Whether or not D-Ser and/or magnesium levels should be checked and possibly dictate therapy is an area of future research. It is also possible that downstream metabolites of ketamine are the key to successful therapy. Keywords: Complex regional pain syndrome; Major Depressive thoughts; and slowing of speech and action. These changes must last a Disorder(MDD); Ketamine minimum of 2 weeks and interfere considerably with work and family relations” [6]. Treatment options include antidepressant medications, Complex Regional Pain Syndrome (CRPS) and Major Depressive cognitive behavioral therapy, and interpersonal therapy.
    [Show full text]
  • ACPA Guide to Pain Management
    [Document title] [Document subtitle] Abstract [Draw your reader in with an engaging abstract. It is typically a short summary of the document. When you’re ready to add your content, just click here and start typing.] ACPA [Email address] 1 ACPA Resource Guide To Chronic Pain Management An Integrated Guide to Medical, Interventional, Behavioral, Pharmacologic and Rehabilitation Therapies 2019 Edition American Chronic Pain Association P.O. Box 850 Rocklin, CA 95677 Tel 800-533-3231 Fax 916-652-8190 E-mail [email protected] Web Site http://www.theacpa.org Copyright 2019 American Chronic Pain Association, Inc. All rights reserved. No portion of this book may be reproduced without permission of the American Chronic Pain Association, Inc. 2 Table of Contents A STATEMENT FROM THE ACPA BOARD OF DIRECTORS ...........................................................................................................................5 INTRODUCTION ........................................................................................................................................................................................................6 OVERVIEW OF CHRONIC PAIN TREATMENT ..................................................................................................................................................8 WHAT DOES SUCCESSFUL PAIN TREATMENT LOOK LIKE? .......................................................................................................................8 PAIN TYPES, SOURCES & CLASSIFICATION .....................................................................................................................................................9
    [Show full text]
  • Membrane Stabilizer Medications in the Treatment of Chronic Neuropathic Pain: a Comprehensive Review
    Current Pain and Headache Reports (2019) 23: 37 https://doi.org/10.1007/s11916-019-0774-0 OTHER PAIN (A KAYE AND N VADIVELU, SECTION EDITORS) Membrane Stabilizer Medications in the Treatment of Chronic Neuropathic Pain: a Comprehensive Review Omar Viswanath1,2,3 & Ivan Urits4 & Mark R. Jones4 & Jacqueline M. Peck5 & Justin Kochanski6 & Morgan Hasegawa6 & Best Anyama7 & Alan D. Kaye7 Published online: 1 May 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose of Review Neuropathic pain is often debilitating, severely limiting the daily lives of patients who are affected. Typically, neuropathic pain is difficult to manage and, as a result, leads to progression into a chronic condition that is, in many instances, refractory to medical management. Recent Findings Gabapentinoids, belonging to the calcium channel blocking class of drugs, have shown good efficacy in the management of chronic pain and are thus commonly utilized as first-line therapy. Various sodium channel blocking drugs, belonging to the categories of anticonvulsants and local anesthetics, have demonstrated varying degrees of efficacy in the in the treatment of neurogenic pain. Summary Though there is limited medical literature as to efficacy of any one drug, individualized multimodal therapy can provide significant analgesia to patients with chronic neuropathic pain. Keywords Neuropathic pain . Chronic pain . Ion Channel blockers . Anticonvulsants . Membrane stabilizers Introduction Neuropathic pain, which is a result of nervous system injury or lives of patients who are affected. Frequently, it is difficult to dysfunction, is often debilitating, severely limiting the daily manage and as a result leads to the progression of a chronic condition that is, in many instances, refractory to medical This article is part of the Topical Collection on Other Pain management.
    [Show full text]
  • Intrathecal Drug Infusions
    INTRATHECAL DRUG INFUSIONS RATIONAL USE OF POLYANALGESIA TIMOTHY R. DEER, MD • PRESIDENT AND CEO, THE CENTER FOR PAIN RELIEF, CHARLESTON, WEST VIRGINIA • CLINICAL PROFESSOR OF ANESTHESIOLOGY, WEST VIRGINIA UNIVERSITY • BOARD OF DIRECTORS, INTERNATIONAL NEUROMODULATION SOCIETY • IMMEDIATE PAST CHAIR, AMERICAN SOCIETY OF ANESTHESIOLOGISTS, COMMITTEE ON PAIN MEDICINE • BOARD OF DIRECTORS; AMERICAN ACADEMY OF PAIN MEDICINE AND AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 2 INS 2009 • SYMPOSIUM ON INTRATHECAL DRUG DELIVERY • DISCLOSURES IN INTRATHECAL DRUG DELIVERY • CONSULTANT: INSET, JOHNSON AND JOHNSON. Intrathecal Pump for Pain ! 1 mg intrathecal morphine = 300 mg oral morphine CONFIDENTIAL Krames ES. J Pain Symptom Manage. 1996 Jun;11(6):333-52 4 Objectives • Review current options for pump infusions • Build on the talks of Dr. Levy and Dr. Abejon • Use a case based approach to discuss the issues • Make conclusions regarding the algorithm of Intrathecal analgesia Clinical Decision Making • Regulatory Approval in your country • Case reports • Lectures and anecdotal information • Retrospective analysis • Double-blind, randomized, prospective studies • Physician innovation with no available evidence • Consensus Statements 2000 Guidelines for Intraspinal Infusion 2007 Polyanalgesic Consensus Guidelines for Management of Pain by Intraspinal Drug Delivery Line 1 Morphine or Hydromorphone or Ziconotide Fentanyl or Clonodine alone OR one of the following 2-drug Line 2 combinations: • Morphine (or Hydromorphone) + Ziconotide • Morphine (or
    [Show full text]
  • Drug and Medication Classification Schedule
    KENTUCKY HORSE RACING COMMISSION UNIFORM DRUG, MEDICATION, AND SUBSTANCE CLASSIFICATION SCHEDULE KHRC 8-020-1 (11/2018) Class A drugs, medications, and substances are those (1) that have the highest potential to influence performance in the equine athlete, regardless of their approval by the United States Food and Drug Administration, or (2) that lack approval by the United States Food and Drug Administration but have pharmacologic effects similar to certain Class B drugs, medications, or substances that are approved by the United States Food and Drug Administration. Acecarbromal Bolasterone Cimaterol Divalproex Fluanisone Acetophenazine Boldione Citalopram Dixyrazine Fludiazepam Adinazolam Brimondine Cllibucaine Donepezil Flunitrazepam Alcuronium Bromazepam Clobazam Dopamine Fluopromazine Alfentanil Bromfenac Clocapramine Doxacurium Fluoresone Almotriptan Bromisovalum Clomethiazole Doxapram Fluoxetine Alphaprodine Bromocriptine Clomipramine Doxazosin Flupenthixol Alpidem Bromperidol Clonazepam Doxefazepam Flupirtine Alprazolam Brotizolam Clorazepate Doxepin Flurazepam Alprenolol Bufexamac Clormecaine Droperidol Fluspirilene Althesin Bupivacaine Clostebol Duloxetine Flutoprazepam Aminorex Buprenorphine Clothiapine Eletriptan Fluvoxamine Amisulpride Buspirone Clotiazepam Enalapril Formebolone Amitriptyline Bupropion Cloxazolam Enciprazine Fosinopril Amobarbital Butabartital Clozapine Endorphins Furzabol Amoxapine Butacaine Cobratoxin Enkephalins Galantamine Amperozide Butalbital Cocaine Ephedrine Gallamine Amphetamine Butanilicaine Codeine
    [Show full text]
  • Future Local Anesthetics: Neurotoxins?
    FUTURE PERSPECTIVE Future local anesthetics: Neurotoxins? Prasanna Vadhanan C. MD*, Adhinarayanan S, DA, DNB** *Associate Professor, Department of Anesthesiology, Vinayaka Mission’s Medical College & Hospitals (VMMCH),Karaikal (India) **Associate Professor, Department of Anesthesiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry (India) Correspondence: Dr. Prasanna Vadhanan, Associate Professor, Department of Anesthesiology, Vinayaka Mission’s Medical College & Hospitals (VMMCH), Karaikal (India) ABSTRACT This review article gives a look into the efforts being made to develop local anesthetics from new molecules, thus offering a better safety profile. Neurotoxins are a varied group of compounds, both chemically and pharmacologically. These encompass a wide group of drugs which acts on various ionic channels like sodium, potassium, calcium and chloride channels. The differences between current agents and the new group are presented. Tetrodotoxin and saxitoxin (STX) are the two more prominent groups of neurotoxins. Their characteristics are outlined. Key words: Local anesthetics; Neurotoxins; Tetrodotoxin; Saxitoxin Citation: Vadhanan P, Adhinarayanan S. Future local anesthetics: Neurotoxins?. Anaesth Pain & Intensive Care 2014;18(3):308-312 INTRODUCTION properties The use of cocaine by Koller in 1884 heralded a new class 1. No or minimal systemic toxicity of drugs which would later prove indispensable in routine 2. Longer shelf life anesthesia practice. Local anesthetic agents are one of the 3. Better sensory motor separation most widely used drugs for providing and or supplementing 4. Prolonged action analgesia . Lignocaine (1943) and bupivacaine (1963), 5. Stability quickly replaced cocaine and procaine because of their 6. No tissue irritation better safety profile. Even with the introduction of newer 7. Easily metabolized local anesthetics like ropivacaine and levobupivacaine, the By the current knowledge of NaV isoforms, it would be search for the ideal local anesthetic is still on.
    [Show full text]
  • Conotoxins As Tools to Understand the Physiological Function of Voltage-Gated Calcium (Cav) Channels
    marine drugs Review Conotoxins as Tools to Understand the Physiological Function of Voltage-Gated Calcium (CaV) Channels David Ramírez 1,2, Wendy Gonzalez 1,3, Rafael A. Fissore 4 and Ingrid Carvacho 5,* 1 Centro de Bioinformática y Simulación Molecular, Universidad de Talca, 3460000 Talca, Chile; [email protected] (D.R.); [email protected] (W.G.) 2 Instituto de Ciencias Biomédicas, Universidad Autónoma de Chile, 3460000 Talca, Chile 3 Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Universidad de Talca, 3460000 Talca, Chile 4 Department of Veterinary and Animal Sciences, University of Massachusetts, Amherst, MA 01003, USA; rfi[email protected] 5 Department of Biology and Chemistry, Faculty of Basic Sciences, Universidad Católica del Maule, 3480112 Talca, Chile * Correspondence: [email protected]; Tel.: +56-71-220-3518 Received: 8 August 2017; Accepted: 4 October 2017; Published: 13 October 2017 Abstract: Voltage-gated calcium (CaV) channels are widely expressed and are essential for the completion of multiple physiological processes. Close regulation of their activity by specific inhibitors and agonists become fundamental to understand their role in cellular homeostasis as well as in human tissues and organs. CaV channels are divided into two groups depending on the membrane potential required to activate them: High-voltage activated (HVA, CaV1.1–1.4; CaV2.1–2.3) and Low-voltage activated (LVA, CaV3.1–3.3). HVA channels are highly expressed in brain (neurons), heart, and adrenal medulla (chromaffin cells), among others, and are also classified into subtypes which can be distinguished using pharmacological approaches. Cone snails are marine gastropods that capture their prey by injecting venom, “conopeptides”, which cause paralysis in a few seconds.
    [Show full text]
  • 2 12/ 35 74Al
    (12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT) (19) World Intellectual Property Organization International Bureau (10) International Publication Number (43) International Publication Date 22 March 2012 (22.03.2012) 2 12/ 35 74 Al (51) International Patent Classification: (81) Designated States (unless otherwise indicated, for every A61K 9/16 (2006.01) A61K 9/51 (2006.01) kind of national protection available): AE, AG, AL, AM, A61K 9/14 (2006.01) AO, AT, AU, AZ, BA, BB, BG, BH, BR, BW, BY, BZ, CA, CH, CL, CN, CO, CR, CU, CZ, DE, DK, DM, DO, (21) International Application Number: DZ, EC, EE, EG, ES, FI, GB, GD, GE, GH, GM, GT, PCT/EP201 1/065959 HN, HR, HU, ID, IL, IN, IS, JP, KE, KG, KM, KN, KP, (22) International Filing Date: KR, KZ, LA, LC, LK, LR, LS, LT, LU, LY, MA, MD, 14 September 201 1 (14.09.201 1) ME, MG, MK, MN, MW, MX, MY, MZ, NA, NG, NI, NO, NZ, OM, PE, PG, PH, PL, PT, QA, RO, RS, RU, (25) Filing Language: English RW, SC, SD, SE, SG, SK, SL, SM, ST, SV, SY, TH, TJ, (26) Publication Language: English TM, TN, TR, TT, TZ, UA, UG, US, UZ, VC, VN, ZA, ZM, ZW. (30) Priority Data: 61/382,653 14 September 2010 (14.09.2010) US (84) Designated States (unless otherwise indicated, for every kind of regional protection available): ARIPO (BW, GH, (71) Applicant (for all designated States except US): GM, KE, LR, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, NANOLOGICA AB [SE/SE]; P.O Box 8182, S-104 20 ZM, ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, Stockholm (SE).
    [Show full text]
  • Prescription Medications, Drugs, Herbs & Chemicals Associated With
    Prescription Medications, Drugs, Herbs & Chemicals Associated with Tinnitus American Tinnitus Association Prescription Medications, Drugs, Herbs & Chemicals Associated with Tinnitus All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form, or by any means, without the prior written permission of the American Tinnitus Association. ©2013 American Tinnitus Association Prescription Medications, Drugs, Herbs & Chemicals Associated with Tinnitus American Tinnitus Association This document is to be utilized as a conversation tool with your health care provider and is by no means a “complete” listing. Anyone reading this list of ototoxic drugs is strongly advised NOT to discontinue taking any prescribed medication without first contacting the prescribing physician. Just because a drug is listed does not mean that you will automatically get tinnitus, or exacerbate exisiting tinnitus, if you take it. A few will, but many will not. Whether or not you eperience tinnitus after taking one of the listed drugs or herbals, or after being exposed to one of the listed chemicals, depends on many factors ‐ such as your own body chemistry, your sensitivity to drugs, the dose you take, or the length of time you take the drug. It is important to note that there may be drugs NOT listed here that could still cause tinnitus. Although this list is one of the most complete listings of drugs associated with tinnitus, no list of this kind can ever be totally complete – therefore use it as a guide and resource, but do not take it as the final word. The drug brand name is italicized and is followed by the generic drug name in bold.
    [Show full text]
  • Practical Considerations in Analgesic Selection for Chronic Noncancer Pain
    Primary Care Pain Management in Pennsylvania: Optimizing Treatment, Minimizing Risk PRACTICAL CONSIDERATIONS IN ANALGESIC SELECTION FOR CHRONIC NONCANCER PAIN MARY LYNN MCPHERSON, PHARMD, MA, BCPS, CPE UNIVERSITY OF MARYLAND SCHOOL OF PHARMACY . LEARNING OBJECTIVES 1. Given an actual or simulated patient with chronic noncancer pain, demonstrate consideration of patient- and drug-related variables in selecting opioid analgesics. 2. Demonstrate competence in basic opioid conversion calculations and opioid dosage titration. 3. Given an actual or simulated patient with chronic noncancer pain, recommend appropriate coanalgesic. WHAT IS PAIN? ¡ “Total” Pain (Dame Cicely Saunders) ¡ Physical (due to disease or treatments) ¡ Psychological (anger, fear of suffering, depression, past experience of illness) ¡ Social (loss of role, status, job; financial concerns, worries about future/ family, dependency) ¡ Spiritual (anger, loss of faith, finding meaning, fear of the unknown ¡ An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP). ¡ “Pain is whatever the person experiencing it says it is” (McCaffery). www.iasp-pain.org/AM/Template.cfm?Sec8on=Home&Template=/CM/ContentDisplay.cfm&ContentID=8705 PATHOGENESIS OF PAIN Pain Nocicep8ve Neuropathic Central or Visceral Somac Peripheral Type of pain How patient’s describe it Analgesics Nociceptive • May be sharp or dull, often aching in nature Responds well to somatic pain • Familiar pain (e.g., toothache) primary analgesics
    [Show full text]
  • The Challenging Task of Erythromelalgia Therapy Maria Cristina Caroleo* and Erika Cione
    Commentary iMedPub Journals Journal of Reproductive Endocrinology & Infertility 2017 http://www.imedpub.com/ Vol.2 No.1:19 ISSN 2476-2008 DOI: 10.4172/2476-2008.100019 The Challenging Task of Erythromelalgia Therapy Maria Cristina Caroleo* and Erika Cione Department of Pharmacy and Health and Nutritional Sciences, University of Calabria, Italy *Corresponding author: Maria Cristina Caroleo, Department of Pharmacy and Health and Nutritional Sciences, University of Calabria, Italy, E-mail: [email protected] Received date: January 25, 2017; Accepted date: February 24, 2017; Published date: February 28, 2017 Copyright: © 2017, Caroleo MC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Commentary pain, redness and occasionally swelling, more commonly affecting legs and/or hands [15]. Symptoms are worsened by Chronic pain is one of the most common symptom seen in the warmth and longtime standing or exercise. The pain attacks are clinical practice; it affects about 30% of adults in the world [1] relieved by cooling, which can become compulsive and result in leading to a poor quality of life and a higher risk to develop co- skin lesions [15]. Treatment of PE is still a challenge in the clinical morbidities such as depression. Available treatments often practice and based on small case series. The therapy is based produce insufficient pain relief; thus the general therapeutic mainly on support and avoidance of trigger factors. While aspirin approach is still a stepwise process aimed to identify which shows efficacy in patients with secondary Erythromelalgia drugs or drug combinations provide the greatest pain relief with caused by myeloproliferative disorders [16] most cases of PE are fewest side-effects.
    [Show full text]