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Treatment

Several treatment modalities are available within the field of neuropathic pain and neuropathy.

Pregabalin, Lyrica® not for fibromyalgia in Europe

The EMEA has adviced against the marketing authorization of Lyrica® in the indication fibromyalgia in Europe. This is their argumentation:

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Cannabis as treatment for intractable abdominal pain syndrome

Treatment resistent abdominal pain, with unknown etiology can sometimes be treated succesfully by Cannabis. It might be that this chronic pain syndrome has something to do with small fiber neuropathy in the innervation network around the gut. But, whatever its etiology, it is merely a hypothesis and very difficult to substantiate. However, having said that, there are patients suffering from for instance diabetic neuropthy, with severe gasterointestinal complaits, and we feel these pains and complaints can be due to small fiber neuropthy. As Cannabis appeared to be a useful drug for treating treatment resistant neuropathic pain, we sometimes prescribe Cannabis to patients suffering from treatment resistent abdominal pain, and we follow the so called ex juvantibus approach. This means we give the patient the befifit of the doubt, that the pain might be caused by an internal neuropathy, and if so, whether the patients responds favourable on a treatment regime withn Cannabis, orally taken.  

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Integrated Medicine concept for neuropathic pain at the Berlin congress (2010)

Treatment of neuropathic pain, an overview presented at the 3rd European Congress for Integrative Medicine,in Berlin, December 3rd, 2010. The founding fathers of the Institute of Neuropathic pain attended the above mentioned congress to present the integrated treatment concept for neuropathic pain to an audience of physicians interested in pain treatment. The director of research and development from the institute, professor Jan M. Keppel Hesselink, presented the multimodal therapy as it has been developed within the institute for the past years.

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vitamin D and chronic pain

Vitamin D could save the country about €37.5 billion in health care costs, according to a new review  of professor A. Zittermann.

Vitamin D
receptors are expressed in many other tissues beyond
the musculoskeletal system, and vitamin D plays protective
physiologic roles against several chronic diseases such
as cancer, osteoarthritis, diabetes, and cardiovascular
conditions. There is clear evidence for an association
between low vitamin D status and pain in the general
population. The chronic pain syndromes included chronic back
pain, chronic musculoskeletal pain or widespread pain, and polymyalgia and in all these cases vitamin D was suggested as the cause of such nonspecific pain.

Vitamin D through its receptor modulates neuronal differentiation as well as neuronal growth and function. In rats, the production of nerve growth factor which is required for the development and survival of both sympathetic and sensory neurons decreases in the presence of vitamin D deficiency. In fact, in vitamin D deficient diabetic animals correction of vitamin D deficiency resulted in an improvement in nerve growth factor production. Decrease in neurotrophins and defective calcium homeostasis leaves the nerve vulnerable to toxins including hyperglycemia. As a result, a deficiency of vitamin D impairs nociceptor function, worsens nerve damage, and lowers the pain threshold.

And: 

In another study vitamin D levels were not only inversely proportional to a neuropathy symptoms score but also showed a statistically significant (OR 3.47 95% CI 1.04–11.56 P = 0.04) association with slower nerve conduction velocities after correction for duration of diabetes and levels of HbA1c, LDL, and urinary albumin

Two qoutes from a recent report were a patient suffering from severe neuropathic diabetic pain, refractory to analgesics, experienced cler pain relief after the correction of the vitamine D deficiency. 

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Ziconotide in chronic pain requiring intraspinal analgesia: orphan drug

Ziconotide is a man-made equivalent of a molecule composed of a 25-amino acid chain, which is found in the venom of a fish-eating marine snail, Conus magus. Ziconotide blocks the action of specific molecules found in nerve tissue, called N-type voltage-sensitive calcium channels. These molecules play an important role in chronic pain. Ziconotide is expected to decrease pain by blocking the function of these molecules.

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Natalizumab in chronic inflammatory demyelinating polyneuropathy (CIDP)

Natalizumab, a humanized monoclonal antibody against the 4 integrin did not help in treating a patient suffering from chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Although experimental evidence in an animal model pointed out that targeting 4 integrins in the inflamed peripheral nervous system may have clinical relevant effects, this was not the case in a patient.

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Pudendal neuralgia responding to a novel use of palmitoylethanolamide

Pudendal neuralgia is the most common and most disabling form of pelvic pain. It presents as unilateral or bilateral burning pain of the anterior or posterior perineum that is worse on sitting and relieved by standing, not usually associated with night pain.This pain is a cause of chronic, disabling, and often intractable perineal pain.

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Occipital Neuralgia Responding to Palmitoylethanolamide

Under the titel ’Occipital Neuralgia Responding to Palmitoylethanolamide’ Rocco Salvatore Calabrò and Placido Bramanti reported a case in ‘Headache’, a female patient affected by occiptal-treatment-refractory-neuralgia that greatly improved after oral intake of palmitoylethanolamide (PEA).

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Duloxetine (Cymbalta®) in urine incontinence and neuropathic pain

On 24 July 2008 the Committee for Medicinal Products for Human Use (CHMP) in Europe adopted a positive opinion, recommending to grant a marketing authorisation for the medicinal product Duloxetine  produced by Boehringer Ingelheim in capsules of 20 mg, 30 mg, 40 mg and 60 mg. The indications are: 

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Motor cortex stimulation (MCS) for neuropathic pain

In the European Journal of Pain Supplements, 19 juli 2010 Garcia–Larrea discussed the value of Motor cortex stimulation (MCS), a relatively recent neurosurgical technique for pain control, in the treatment fo neuropathic pain. This is an abstract of a talk he gave at the  Third International Congress on Neuropathic Pain in Athens earlier this year. We were there and would like to make some commets, as this talk was discussed in great detail by a MD from the UK. She stated that there has not been conducted one methodological acceptable clinical trial analysing the safety and efficacy of this technique.

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Paclitaxel and long-lasting sensory neuropathy

Paclitaxel is an effective chemotherapeutic agent that is widely used for the treatment of several cancers, including breast and ovarium cancer. However, it induces disabling and potentially long-lasting sensory neuropathy. 

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Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb. Surgical sympathectomy has long been seen as a realistic option to treat CRPS. The use of this operation that destroys some of the nerves however has always remain controversial. In a recent Cochrane analysis no evidence could be found. The conclusion was:

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Syringomyelia, pain and its treatment

syringomyelia.jpg Although pain is a prominent symptom in patients suffering from syringomyelia, and this central neuropathic pain is very difficult to treat. However, more than half of all patients with syringomyelia suffer from symptoms related to central neuropathic pain. In the video you can see one of our patients, suffering from syringomyelia telling his story and reporting the effect of our treatment of the neuropathic pain:

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Cannabis cookies for neuropathic pain

Cannabis treatment for meuropathic pain using low dose cannabis during prolonged periods of time due to slow resorption from butter rich cannabis cookies: a better way to administer cannabis than the classical joint or marihuana tea.

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Pregabalin, the lidocaine plaster and duloxetine in refractory neuropathic pain

Numbers needed to treat in neuropathic pain are not very impressive. If you would tell your patient, I have to treat at least 5 patients like you in order to help one of those patients reach a pain reduction of 50%..imagine how many patients would frown and say…excuse me? (if they are British that is..). Because patients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain, the opening sentence of a new (2011) article on refractory neuropathic pain, ‘Pregabalin, the lidocaine plaster and duloxetine in patients with refractory neuropathic pain: a systematic review’ by Melanie Plested and collegues, among which one works at Pfizer’s (interesting..!).

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