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

Rogério Adas Ayres de Oliveira; Abrahão Fontes Baptista; Katia Nunes Sá; Luciana Mendonça Barbosa; Osvaldo José Moreira do Nascimento; Clarice Listik; Xavier Moisset; Manoel Jacobsen Teixeira; Daniel Ciampi de Andrade; Clinicians participants of the panel of experts recommended by the Brazilian Academy of Neurology

doi:10.1590/0004-282X20200166

Arquivos de Neuro-Psiquiatria, Inhaltsverzeichnis

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

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

²Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.
Abrahão Fontes Baptista

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

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

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

²Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.
Osvaldo José Moreira do Nascimento

²Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.

⁵Universidade Federal Fluminense, Faculdade de Medicina, Graduate and Research Program in Neurology/Neurosciences, Niterói RJ, Brazil.
Clarice Listik

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

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

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

⁷Universidade 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

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

²Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.

⁷Universidade de São Paulo, Departamento de Neurologia, Centro de Dor, LIM 62, São Paulo SP, Brazil.

Abstract

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

Volltext

Referenzen

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