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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(11): 741-752
DOI: 10.1590/0004-282X20200166
Brazilian Academy of Neurology

Pharmacological treatment of central neuropathic pain: consensus of the Brazilian Academy of Neurology

Tratamento farmacológico da dor neuropática central: consenso da Academia Brasileira de Neurologia

Authors

  • Rogério Adas Ayres de Oliveira

    1   Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.
    2   Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.

  • Abrahão Fontes Baptista 

    3   Universidade Federal do ABC, Center for Mathematics, Computation and Cognition, São Bernardo do Campo SP, Brazil.

  • Katia Nunes Sá 

    4   Escola Bahiana de Medicina e Saúde Pública, Graduate and Research Department, Salvador BA, Brazil.

  • Luciana Mendonça Barbosa 

    1   Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.
    2   Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.

  • Osvaldo José Moreira do Nascimento 

    2   Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.
    5   Universidade Federal Fluminense, Faculdade de Medicina, Graduate and Research Program in Neurology/Neurosciences, Niterói RJ, Brazil.

  • Clarice Listik 

    1   Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.

  • Xavier Moisset 

    6   Université Clemont Auvergne, Chu de Clermont-Ferrand, INSERM, NEURO-DOL, F-63000 Clermont-Ferrand, France.

  • Manoel Jacobsen Teixeira 

    1   Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.
    7   Universidade de São Paulo, Departamento de Neurologia, Centro de Dor, LIM 62, São Paulo SP, Brazil.
    • Clinicians participants of the panel of experts recommended by the Brazilian Academy of Neurology,

  • Daniel Ciampi de Andrade

    1   Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.
    2   Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.
    7   Universidade de São Paulo, Departamento de Neurologia, Centro de Dor, LIM 62, São Paulo SP, Brazil.
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ABSTRACT

Background: 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. Objective: To develop recommendations for the treatment of CNP in Brazil. Methods: Systematic review, meta-analysis, and specialists opinions considering efficacy, adverse events profile, cost, and drug availability in public health. Results: 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. Conclusions: 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.

RESUMO

Introdução: A dor neuropática central (DNC) é frequentemente refratária às estratégias terapêuticas disponíveis e há poucas opções de tratamento baseado em evidência. Muitos pacientes com dor neuropática não são diagnosticados ou tratados adequadamente. Desse modo, recomendações baseadas em consenso, adaptadas à disponibilidade de medicamentos no país, são necessárias para guiar decisões clínicas. Objetivo: Desenvolver recomendações para o tratamento da DNC no Brasil. Métodos: Revisão sistemática, metanálise e discussão dos resultados entre especialistas e pesquisadores da área, considerando eficácia, perfil de eventos adversos, custo e disponibilidade do fármaco na saúde pública. Resultados: Foram encontrados 44 estudos sobre tratamento da DNC, dos quais 20 foram incluídos na análise qualitativa e 15, na quantitativa. Classificaram-se as medicações em primeira, segunda e terceira linhas de tratamento, baseando-se em revisão sistemática, meta-análise e opinião de especialistas. Como primeira linha, foram incluídos gabapentina, duloxetina e antidepressivos tricíclicos. Como segunda, venlafaxina, pregabalina para DNC secundária à lesão medular, lamotrigina para DNC pós-acidente vascular cerebral e, em associação aos fármacos de primeira linha, opioides fracos, em particular tramadol. Para os pacientes refratários, opioides fortes (metadona e oxicodona) e canabidiol/delta-9-tetrahidrocanabinol foram classificados como terceira linha de tratamento, em associação com drogas de primeira ou segunda linha, e, para DNC na esclerose múltipla, dronabinol. Conclusões: Os estudos que abordam o tratamento da DNC são escassos e heterogêneos, e parte significativa das recomendações é baseada em opiniões de especialistas. A abordagem da DNC deve ser individualizada, levando em conta a disponibilidade de medicação, o perfil de efeitos adversos, incluindo risco de dependência e as comorbidades do paciente.

Keywords:

Pain - Pain management - Neuropathic pain - Drug therapy - Consensus

Palavras-chave:

Dor - manejo da dor - dor neuropática central - tratamento farmacológico - consenso

Author's contribution:

R. A. A. de Oliveira - Methodology, Writing – original draft; A. F. Baptista - Formal Analysis, Writing – original draft; K. N. Sá - Data curation, Formal Analysis; L. M. Barbosa - Funding acquisition, Project administration; O. J. M. do Nascimento – Methodology, Data curation, Visualization; C. Listik - Writing – review & editing; X. Moisset - Formal Analysis, Data curation; M. J. Teixeira - Conceptualization, Methodology; D. C. de Andrade - Conceptualization, Funding acquisition, Project administration, Writing – review & editing; Central Neuropathic Pain Study Group – Methodology, Formal Analysis.




Publication History

Received: 04 July 2020

Accepted: 17 September 2020

Article published online:
07 June 2023

© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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