Abstract
Central neuropathic pain (CNP) is often refractory to available therapeutic strategies and there are few evidence-based treatment options. Many patients with neuropathic pain are not diagnosed or treated properly. Thus, consensus-based recommendations, adapted to the available drugs in the country, are necessary to guide clinical decisions. To develop recommendations for the treatment of CNP in Brazil. Systematic review, meta-analysis, and specialists opinions considering efficacy, adverse events profile, cost, and drug availability in public health. Forty-four studies on CNP treatment were found, 20 were included in the qualitative analysis, and 15 in the quantitative analysis. Medications were classified as first-, second-, and third-line treatment based on systematic review, meta-analysis, and expert opinion. As first-line treatment, gabapentin, duloxetine, and tricyclic antidepressants were included. As second-line, venlafaxine, pregabalin for CND secondary to spinal cord injury, lamotrigine for CNP after stroke, and, in association with first-line drugs, weak opioids, in particular tramadol. For refractory patients, strong opioids (methadone and oxycodone), cannabidiol/delta-9-tetrahydrocannabinol, were classified as third-line of treatment, in combination with first or second-line drugs and, for central nervous system (CNS) in multiple sclerosis, dronabinol. Studies that address the treatment of CNS are scarce and heterogeneous, and a significant part of the recommendations is based on experts opinions. The CNP approach must be individualized, taking into account the availability of medication, the profile of adverse effects, including addiction risk, and patients' comorbidities.
Highlights
Chronic pain is defined as pain in one or more anatomical regions that persists or recurs for longer than three months and is associated with significant emotional distress or functional disability[1]
The prevalence of Central neuropathic pain (CNP) has been less frequently assessed in the general population, but it is estimated to affect a significant proportion of patients with different neurological diseases, such as 18% of stroke survivors who have somatosensory deficits[6], and 59% of those affected by spinal cord injury[7], and at least 30% of multiple sclerosis patients[8]
Summary of classification of selected studies Based on these results and taking into account the positive or negative effects of the drugs, specialists’ opinions, balancing their adverse effects, cost, and availability in SUS, Table 1, Figure 2 and Box 1 summarize the results of the consensus panel according to the use of drugs to treat CNP in Brazil
Summary
Chronic pain is defined as pain in one or more anatomical regions that persists or recurs for longer than three months and is associated with significant emotional distress or functional disability[1]. It affects from 19 to 41% of the general population living in developing countries[2]. Medications were classified as first-, second-, and third-line treatment based on systematic review, meta-analysis, and expert opinion. Strong opioids (methadone and oxycodone), cannabidiol/delta9-tetrahydrocannabinol, were classified as third-line of treatment, in combination with first or second-line drugs and, for central nervous system (CNS) in multiple sclerosis, dronabinol.
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