Neuropathic pain treatment by Dr Nadine Attal

Dr Nadine Attal gave a nice and crisp talk about neuropathic pain treatment. She is a neurologist and pain specialist, Director of the Pain Evaluation and Treatment Center of Hospital Ambroise in France. She is also a member of the INSERM U 792 team.

Dr Attal is a member of several scientific societies, including the Society for Neuroscience, the International Association for the Study of Pain and the American Pain Society.

Pixabay-3184432-INP Dr Nadine Attal (woman on photo is model)She has authored 60 referenced journal articles and over 30 book chapters, has coordinated books on neuropathic pain in France, and is associate editor for the journal Pain.

Definition of neuropathic pain

She recently co-chaired the European Federation of Neurological Societies (EFNS) guidelines on the pharmacological treatment of neuropathic pain. And was involved in the EFNS guidelines on the assessment of neuropathic pain. She also recently joined the NeuroPsig management committee.

Nadine presents the definition of neuropathic pain. She points out that the definition is currently on the move. She presents epidemiological data on neuropathic pain in France, showing that 5-7% of the general population have neuropathic pain syndromes. Most common neuropathic pain syndrome is the radiculopathy.

She discussed the various mechanisms behind neuropathic pain such as excitability (Lidocaine, anti-epileptics), sodium channel blockers, descending control mechanisms (anti-depressants) and central sensitization (pregabalin).

Amitriptyline, Duloxetine

Anti-depressants are the most popular therapy in neuropathic pain, where Amitriptyline is most active and the SSRI’s most weak. Duloxetine is a bit more active compared to SSRI and has intermediate efficacy. 

Among the anti-epileptics, the alpha-2-delta antagonists, such as pregabalin are a step forward. The alpha-2-delta receptor is linked to a calcium channel. Many trials (16+) have been conducted with these antagonists in PHN and PN.

For Gabapentine no clear dose-response curve exists, but it does exist for pregabaline, 600 mg is more effective compared to 300 mg. Nadine made the point that this might be due to the better bio availability.

Regarding the sodium channel blockers there are many conflicting results in the field of diabetic painful neuropathy. Some sodium channel blockers are effective in RCT’s others are not. The idea that opiates are not effective in neuropathic pain has been rejected. 

The building of a treatment algorithm is complicated, as there are only very few comparable drug trials, most RCT’s are dealing with one drug only versus placebo. Meta-analysis show that nearly all drugs are only moderate active, and NNT are not less than 3-4.!

If selecting an analgesic, considering other symptoms as sleep, depression and anxiety, or allodynia help to select the best first line drug. For instance, if allodynia is clearly present, topical Lidocaine should be considered. And in general TENS should not be forgotten.

Future targets might be neuroglia, Cannabinoids and vaniloid agonists, as well as botulinum (intradermally in painful area in case of allodynia).

May 2010, Jan M. Keppel Hesselink, MD, PhD
‘Neuropathic pain treatment as presented by Dr Nadine Attal’

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