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EFNS Guidelines on Neuropathic Pain Assessment

EFNS Guidelines on Neuropathic Pain Assessment. Dr.ssa G Di Stefano Prof. G. Cruccu Dipartimento di Neurologia e Psichiatria, Università “Sapienza” di Roma. Dolore neuropatico. Neuropathic pain is pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.

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EFNS Guidelines on Neuropathic Pain Assessment

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  1. EFNS Guidelines on Neuropathic Pain Assessment Dr.ssa G Di Stefano Prof. G. Cruccu Dipartimento di Neurologia e Psichiatria, Università “Sapienza” di Roma

  2. Dolore neuropatico Neuropathic pain is pain arising as a direct consequence of a lesion or disease affecting the somatosensory system Treede et al., Neurology 2008

  3. Current therapeutic targets

  4. Current therapeutic targets • Nerve excitability • Peripheral sensitization • Topical lidocaine • Capsaicin • Sodium channel blockers

  5. Current therapeutic targets • Nociceptive transmission • Central sensitization • 2δ ligands (Gabapentin, Pregabalin)

  6. Sensitizzazione centrale

  7. Current therapeutic targets • Nociceptive transmission • Central sensitization • 2δ ligands (Gabapentin, Pregabalin)

  8. Current therapeutic targets • Descending control • Segmental inhibition • Antidepressant (SNRI, TCA) • Opioids (Tramadol, Oxycodone)

  9. Future therapeutic targets • Nerve excitability • Peripheral sensitization • Novel Sodium channel blockers (Ralfinamide) • Potassium channel blockers (Retigabine) • Gene expression • GDNF, Anti-NGF Nociceptive transmission Central sensitization AMPA antagonists (Terampanel) Microglial activation - Cytokine inhibitors - MAPK inhibitors

  10. EFNS guidelines Attal et al., Eur J Neurol 2010

  11. Recommendations from EFNS guidelines Attal et al., Eur J Neurol. 2010

  12. Opioid use Italy Breivik et al., Ann Oncol 2009

  13. Safety concerns about opioids • The lack of long-term studies of opioids in chronic non-cancer patients pain was one of the main objections raised in published guidelines and reccomendations1 • One study of slow-release oxycodone (average dose 52.5 mg) followed-up 233 patients for 36 months2 • 10% of patients required an increase in their average daily dose from month 122 • 2.6% developed abuse/dependency2 • However, these are only the first results. More controlled, long-term studies, and QoL assessments are needed1 1. Attal et al., Eur J Neurol 2010; 2. Portenoy et al., Clin J Pain 2007

  14. Opioid adverse events Kalso et al., Pain 2004

  15. Oxycodone - Naloxone Changes in bowel function index Oxy-N vs Oxy Changes in intensity of pain Oxy-N vs Oxy Clemens et al., Int J Clin Pract. 2011

  16. Recommendations from EFNS guidelines Attal et al., Eur J Neurol. 2010

  17. RCT in central post-stroke pain

  18. RCT in Multiple Sclerosis-related pain Truini et al., Expert Opin Pharmacother 2011

  19. Guidelines on neuropathic pain treatment

  20. Guidelines on neuropathic pain treatment

  21. 13% of patients suffering from PHN did not receive any treatment: low pain intensity or underestimation of PHN in clinical practice?; • Nearly 25% of patients was treated with a 1st medication, alone or in combination with other treatments: did clinicians neglect evidence-based recommendations? • More than 50% of patients started the treatment with 2nd or 3rd line medications; • Nearly 25% of patients was treated with a 3rd line medication, or a not-recommended one: role of the clinical practice against evidence based recommendations.

  22. THANK YOU!

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