The treatment of neuropathic pain is sometimes difficult and is generally based on the combination of several medicinal and/or non-medicinal methods. Seeking the best relief with the fewest possible side effects is the rule. Of course, if there is a specific pathology responsible for the neuropathy (diabetes, inflammatory disease, etc.), the treatment of the underlying pathology can in certain cases cure the neuropathy.
Several types of molecules are effective on neuropathic pain at the cost, for some, of significant side effects:
Antidepressants. Two large families of antidepressants have their own analgesic effect:
Amitriptyline (Laroxyl) and Clomipramine (Anafranil). Amytriptyline is more sedating than Clomipramine. The doses used are, in general, lower than the antidepressant doses. The analgesic effect only appears after a delay of 2 to 3 weeks.
Mianserin and mirtazapine have also shown moderate analgesic properties in neuropathic pain and fibromyalgia. The effect is also delayed by approximately 3 weeks between the start of treatment and the analgesic effect.
Serotonin reuptake inhibitors:
Also inhibit norepinephrine reuptake: Duloxetine (Cymbalta), Milnacipran (Ixel), Venlafaxine (Effexor). Serotonin inhibitors alone do not have analgesic effects. The doses to obtain an analgesic effect are often lower than the antidepressant doses. The analgesic effect only appears after 3 weeks of treatment.
Essentially prescribed for background pain such as burning. Not very effective on pain with electric shocks.
- Carbamazepine (Tegretol).
- Oxcarbazepine (Trileptal)
- Gabapentin (Neurontin).
- Pregabalin (Lyrica).
- Clonazepam (Rivotril) and other benzodiazepines.
Carbamazepine and oxcarbazepine have an effect on flash pains, electric shocks but are not very effective on continuous pain, in particular burns. Gabapentin and Pregabalin are effective for ongoing neuropathy pain and electric shock pain. Clonazepam and related products are effective on lightning pains of the type of electric shock, they are also effective on muscle pain (contractures, spasms). Their interest is greatly diminished by the phenomena of dependence induced by these treatments.
The use of these different treatments will depend on the character of the chronic pain and their tolerance, which is extremely variable from one patient to another.
- Paracetamol. This level 1 analgesic (classification according to the WHO) has no effect on neuropathic pain
- Nonsteroidal anti-inflammatory drugs, acetylsalicylic acid. They have little effect on neuropathic pain
- Corticosteroids. They have no direct effect on neuropathic pain, however in certain canal or compressive pathologies (carpal tunnel syndrome, acute sciatica) they reduce pain by reducing the nervous and peri-nervous edema responsible for all or part of the compression.
- Nefopam. Not indicated in the disease-modifying treatment of neuropathic pain. Can sometimes work as an adjunctive treatment.
- Morphine derivatives (codeine, tramadol, buprenorphine). Some patients can be improved by this type of molecules but this is not the generality
- Opioids (morphine, oxycodone, sophidone, fentanyl). Some neuropathies can be improved by these molecules. It seems that oxycodone would have slightly more marked analgesic effects than morphine on this type of pain.
This chili pepper derivative reduces painful surface sensations. Qutenza is an 8% capsaicin patch that is applied between 30 minutes and 1 hour on the painful area every 3 months or so. There are lower dose cream forms available in other countries.
Ketamine and other NMDA blockers.
The leader of this drug class is ketamine.
Some doctors also use intravenous lidocaine for this indication, but beware the use of this medication intravenously can be dangerous: an overdose can cause convulsions and cardiac arrest. Its use is only conceivable, at certain doses, under continuous monitoring of the heart rate.
Mexiletine also has anti-NMDA properties used mainly in myotonic pathologies.
Memantine used in Alzheimer’s disease.
Used in some countries as a treatment for pain related to spasticity, in particular MS (multiple sclerosis). Used in some neuro
Versatis 5% lidocaine plaster works well on certain very superficial neuropathies. It has marketing authorization in France for post zoster pain.
This molecule is beginning to be used in certain neuropathic pains essentially in the same indication as alcoholizations of the nerve or ganglion carried out previously. The interest is the reversible and non-damaging side of the molecule.
Would have positive effects on the recovery of diabetic neuropathies (in association with glycemic regulation). One can imagine that the effect must be similar on neuropathies, in particular deficiency, during treatment.
- Transcutaneous electrical nerve stimulation.
- Spinal electrical neurostimulation.
- Transcranial magnetic neurostimulation.
- Intracranial electrical neurostimulation.
- Local invasive neurostimulation.