Radikülopati ve Pleksopatilerde Nöropatik Ağrının Medikal Tedavisi
Özet
Nöropatik ağrı, sinir sistemindeki lezyon veya disfonksiyon sonucu oluşan, nosiseptif ağrıdan farklı mekanizmaya sahip ve tedavisi güç kronik bir durumdur. Uluslararası kılavuzlarda trisiklik antidepresanlar (özellikle amitriptilin), serotonin-norepinefrin geri alım inhibitörleri (duloksetin, venlafaksin) ve gabapentinoidler (gabapentin, pregabalin) birinci basamak medikal tedavi olarak önerilmektedir. Pregabalin, kalsiyum kanallarına afinitesi ve protein bağımsız emilimi nedeniyle gabapentine göre daha yüksek analjezik potense sahiptir. Tramadol ikinci basamak; güçlü opioidler, kannabinoidler ve antiepileptikler ise yan etki ile bağımlılık riskleri sebebiyle üçüncü veya dördüncü basamakta yer alır. Odaklanmış ağrılarda topikal lidokain ve kapsaisin tercih edilirken, dirençli vakalarda etkinlik ve yan etki dengesi gözetilerek kombinasyon tedavileri uygulanabilir. İlaçların 3-8 haftalık deneme süreleri bulunmakta, doz ayarlamaları kardiyak riskler ve böbrek/karaciğer yetmezlikleri dikkate alınarak bireyselleştirilmektedir. Tedavinin etkinliği hastanın komorbiditelerine, psikolojik durumuna ve uyku bozukluğu gibi semptomlara göre şekillenmektedir.
Neuropathic pain is a chronic condition caused by a primary lesion or dysfunction in the nervous system, possessing a different mechanism than nociceptive pain, which complicates its treatment. International guidelines recommend tricyclic antidepressants (especially amitriptyline), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), and gabapentinoids (gabapentin, pregabalin) as first-line medical treatments. Due to higher affinity for calcium channels and protein-independent absorption, pregabalin exhibits higher analgesic potency compared to gabapentin. Tramadol is suggested as second-line, whereas strong opioids, cannabinoids, and antiepileptics are categorized as third or fourth-line options due to potential side effects and addiction risks. Topical lidocaine and capsaicin are preferred for localized pain, and combination therapies can be utilized in resistant cases to balance efficacy and tolerability profiles. These medications require a trial period of 3 to 8 weeks, and dosage adjustments must be individualized by considering cardiac risks, renal impairment, and hepatic failure. The success of the treatment depends heavily on evaluating the patient's comorbidities, psychological status, and associated symptoms like sleep disturbances.
Referanslar
Merskey, H. and Bogduk, N. Classification of chronic pain. 2nd Edition. IASP Press, Seattle 1994:59-71.
Moulin D, Boulanger A, Clark AJ, Clarke H, Dao T, Finley GA, et al. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014;19:328–235.
Smith BH, Torrance N. Epidemiology of neuropathic pain and its impact on quality of life. Curr Pain Headache Rep. 2012;16:191–198.
Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14:162–173.
Jensen TS, Madsen CS, Finnerup NB. Pharmacology and treatment of neuropathic pains. Curr Opin Neurol 2009;22(5):467–474.
Mu A, Weinberg E, Moulin DE, Clarke H. Pharmacological management of chronic neuropathic pain. Review of the Canadian Pain Society consensus statement. Can Fam Physician. 2017;63:844–852.
Zilliox LA. Neuropathic Pain. Continuum. 2017;23(2): 512-532.
Sumitani M, Sakai T, Matsuda Y,Abe H, Yamaguchi S, Hosokawa T, et al. Executive summary of the clinical guidelines of pharmacologic therapy for neuropathic pain: Second edition by the Japanese Society or Pain Clinicians. J Anesth. 2018; 32(3):463–478.
Dworkin RH, O’Connor AB, Audette J, Baron R, Gourlay GK, Haanpaa ML, et al. Recommendations for the pharmacological management of neuropathic pain: An overview and literature update. Mayo Clinic Proc. 2010;85(3, Suppl):3–14.
Bymaster FP, Dreshfeld-Ahmad LJ, Threlkeld PG, Shaw JL, Thompson L, Nelson DL, et al. Comparative affnity of duloxetine and venlafaxine for serotonin and norepinephrine transporters in vitro and in vivo, human serotonin receptor subtypes, and other neuronal receptors. Neuropsychopharmacology. 2001;25(6):871-888.
Richelson E. Pharmacology of antidepressants. Mayo Clin Proc. 2001;76(5):511-527.
Wright A, Luedtke KE, Vandenberg C. Duloxetine in the treatment of chronic pain due to fbromyalgia and diabetic neuropathy. J Pain Res. 2010;4:1-10.
Barowsky J, Schwartz TL. An evidence-based approach to augmentation and combination strategies for: treatment-resistant depression. Psychiatry (Edgmont). 2006;3(7):42-61.
Luo ZD, Chaplan SR, Higuera ES, Sorkin LS, Stauderman KA, Williams ME, et al. Upregulation of dorsal root ganglion (alpha)2(delta) calcium channel subunit and its correlation with allodynia in spinal nerve-injured rats. J Neurosci. 2001;21(6):1868–1875.
Stahl SM, Porreca F, Taylor CP, Cheung R, Thorpe AJ, Clair A. The diverse therapeutic actions of pregabalin: is a single mechanism responsible for several pharmacological activities? Trends Pharmacol Sci. 2013;34:332–339.
Bockbrader HN, Wesche D, Miller R, Chapel S, Janiczek N, Burger P, et al. A comparison of the pharmacokinetics and pharmacodynamics of pregabalin and gabapentin. Clin Pharmacokinet. 2010;49:661–669.
Attal N, Cruccu G, Baron R, Haanpaa M, Hansson P, Jensen TS, et al. European Federation of Neurological Societies. EFNS guidelines on the pharmacological treatment of neuropathic pain. Eur J Neurol. 2010;17:e67–88.
Moulin DE, Clark AJ, Gilron I, Ware MA, Watson CP, Sessle BJ, et al. Pharmacological management of chronic neuropathic pain – consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage. 2007;12(1):13–21.
Cheville AL, Sloan JA, Northfelt DW, Jillella AP, Wong GY, Bearden LJD, et al. Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: A phase III double-blind crossover study (N01CB). Support Care Cancer. 2009;17(4):451–460
Ho KY, Huh BK, White WD, Yeh CC, Miller EJ. Topical amitriptyline versus lidocaine in the treatment of neuropathic pain. Clin J Pain. 2008;24 (1):51–55.
Casale R, Symeonidou Z, Bartolo M. Topical treatments for localized neuropathic pain. Curr Pain Headache Rep. 2017;21(3):15.
Anand P, Bley K. Topical capsaicin for pain management: Therapeutic potential and mechanisms of action of the new high-concentration capsaicin 8% patch. Br J Anaesth. 2011;107(4):490–502.
Fornasari D. Pain pharmacology: focus on opioids. Clin Cases Miner Bone Metab. 2014;11:165–8.
Baron R, Binder A, Wasner G. Neuropathic pain: Diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol. 2010;9(8):807–819.
Beltramo M. Cannabinoid type 2 receptor as a target for chronic pain. Mini Rev Med Chem. 2009;9:11–25.
Beltramo M, Bernardini N, Bertorelli R, et al. CB2 receptormediated antihyperalgesia: possible direct involvement of neural mechanisms. Eur J Neurosci. 2006;23:1530–1538.
Tarride JE, Collet JP, Choinie`re M, Rousseau C, Gordon A. The economic burden of neuropathic pain in Canada. J Med Econ. 2006;9:55–68.
Gilron I, Jensen TS, Dickenson AH. Combination pharmacotherapy for management of chronic pain: from bench to bedside. Lancet Neurol. 2013;12:1084–1095.
