Neuropathic pain. Neuropathic pain treatment with folk remedies

Painful sensations, regardless of their location, bring a lot of discomfort to a person. In no case should they be ignored, as they are a signal from our body about the changes taking place in it. Especially discomfort give a person strong, as well as constant pain. If they are neuropathic in nature, then this phenomenon can lead a person to the development of severe depression. But what is this pathology, why does it develop and how can it be treated?

How does neuropathic pain manifest? Symptoms

Neuropathic pain can manifest itself in different ways. In certain cases it leads to the emergence of permanent painful sensations, causes a tingling and burning sensation. The pain is localized in the extremities, most often in the area of ​​the fingers. Most often, such pains are not very intense and do not bother the person much, but in certain cases they are characterized by strength and duration.

Also, neuropathic pain can be of a squeezing or constricting nature, they are fixed in the area of ​​the legs, namely in the area of ​​​​the feet or legs, but they can also affect other parts of the body. This symptom significantly interferes with normal life activities and is often accompanied by other pain; it is difficult to correct.

Neuropathic pain is sometimes short-term or acute in nature, and can be localized in the limbs and fingers. In this case, the symptom may be felt in a finger on one hand for a few seconds, after which it moves to another part of the body. It may well be that this phenomenon is provoked by a spasm of nerve endings and subsequent signal transmission to the brain.

Sometimes neuropathic pain occurs hypersensitivity to different kinds of touches. A proportion of patients even shudder at the slightest impact; they try to wear only soft and as imperceptible clothing as possible, and sleep without changing position, wrapped in a blanket, since turning over can lead to awakening.

There is another type of neuropathic pain that causes a feeling of cold. In particular, this problem is often localized in the limbs, and especially in the fingers. The patient may feel as if he has frozen an arm or leg, and in certain cases he is also bothered by numbness.

Why does neuropathic pain occur? Causes

Neuropathic pain can be triggered by herpes zoster; this complication most often develops in mature age. In addition, such a pathology can develop against the background of diabetes mellitus, in which case elevated glucose levels cause impaired activity of the nervous system. Another reason similar condition– this is the development of post-stroke central pain, which lasts from one month to about one and a half years. Also, neuropathic pain can develop against the background of spinal cord injuries, or appear as a result of surgical interventions and suturing. In certain cases, their cause lies in neuralgia trigeminal nerve and back problems. Among other things, they are sometimes provoked by amputation, the development of multiple sclerosis and AIDS. There is evidence that this phenomenon sometimes develops as a result of chemical or radiation influences.

What should those diagnosed with neuropathic pain do? Treatment of the condition

Therapy for neuropathic pain should begin exclusively with identifying the causes of the development of such a symptom. Only by identifying the factor that caused the pathology can you take measures to eliminate it and cope with unpleasant symptoms. So, if the disease develops against the background of spinal injuries, it is worth correcting them. If you have diabetes, you need to carefully monitor your blood sugar levels.

If we talk about eliminating pain, which is certainly the most important thing for every patient, complex therapy is carried out in several directions. The use of ordinary analgesics, which are familiar to each of us, does not give a positive effect, since the unpleasant symptoms are of a completely different nature. Quite often, doctors prescribe anticonvulsant medications to patients, which can relieve tension from the muscles, as well as from the blood vessels.

An important component drug therapy There are different antidepressants. Such medications optimize the activity of the nervous system and reduce the patient’s symptoms, also eliminating irritability, which only aggravates unpleasant symptoms.

In the presence of inflammatory processes in the body, the use of non-steroidal anti-inflammatory medicinal compounds will be beneficial.

To correct especially intense painful sensations, the doctor can select narcotic medications for the patient that have an effective analgesic effect. However, long-term use of such drugs is impossible, since they are addictive and have a rather negative effect on the body.

To achieve the most positive effect, it is advisable to combine several medications. It is worth considering that in certain cases, the use of physiotherapy or acupuncture techniques gives good results.

Neuropathic pain is quite treatable, provided that treatment is carried out under the supervision of a qualified doctor.

Neuropathic pain is a pathological condition manifested by a restructuring of the somatosensory processing of body signals, which leads to the manifestation of a pronounced pain syndrome. This symptom progresses due to damage or dysfunction peripheral nerves– both one and several at once. This can occur as a result of a pinched nerve fiber or a disruption in its nutrition.

• Etiology
• Varieties
• Symptoms
• Diagnostics
• Treatment
• Prevention

Due to damage, the affected fiber ceases to function normally and sends incorrect signals to the brain. For example, a nerve can transmit a signal to the brain that a person has touched a hot object, but at this time nothing of the kind happens. But the brain sends back a signal and absolutely healthy place the patient begins to feel a strong burning sensation, as if from a burn. Most often, this pathological condition manifests itself when various pathologies central nervous system, endocrine system, traumatization certain parts bodies and so on.

Since neuropathic pain occurs without the influence of any external factors, the causes should be sought in the human body itself. Doctors identify several diseases and infections that can cause such a disease. Among them:

Etiology of neuropathic pain

• nerve damage in diabetes. Develops with increased content sugar in the bloodstream. Half of people who have diabetes suffer from neuropathic pain. In them, it usually manifests itself as a feeling of tingling and burning in the feet. Unpleasant sensations intensify during sleep or when wearing tight shoes;
• herpes rash. The pain usually appears after shingles. It is most often observed in elderly people. Duration - up to three months. Characterized by severe discomfort and increased sensitivity in the place where the rash was, sleep disturbances. Also sometimes occurs when clothing or bedding touches the body;
• various spinal cord injuries. Often such injuries lead to damage to the nerves in spinal cord, and are directly related to this type of pain. Pathological process accompanied by tingling throughout the body;
• . Neuropathic pain may appear several years after the attack. Patients usually feel constant cold hands The cause is damage to the nerves of the brain;
• surgical intervention. A feeling of tingling and numbness at the site of the suture constantly worries such people;
• back injuries. In this case, such a pathological condition manifests itself in the form of shooting pain from the lower back to the feet;
• damage to the elbow joints. Neuropathic pain in the elbows is an occupational disease of people who at work are often forced to rest on their elbows or hold their arms suspended;
• radiation;

Varieties

Just like ordinary pain, neuropathic pain can occur in acute or chronic form. But there are other types:

• moderate - tingling sensation in the arms or legs;
• pressing - the main place of manifestation is the feet or lower legs. Often makes walking difficult and brings discomfort to a person’s life;
• short-term - lasts only a few seconds, after which it disappears completely or moves to a new area;
• increased sensitivity.

Symptoms

The main symptom of neuropathic pain is periodic feeling burning, numbness or tingling, as well as pain. The localization of such sensations depends on the causes of their occurrence. In addition to the superficial feeling, the pain can penetrate deeper and be permanent.

Symptoms of neuropathic pain

Among the symptoms that are accompanied by the above unpleasant feelings, are observed:

• sleep disturbance due to increased sensitivity and short-term pain;
• constant anxiety, which can develop into depression;
• decreased quality of life, which is directly affected by uncomfortable feelings.

Diagnostics

There are no specific diagnostic measures to determine neuropathic pain. To confirm the diagnosis, doctors use standard procedures and tests that evaluate the symptoms and causes of such pain.

Diagnosis is based on a detailed interview with the patient. This is necessary to compile a complete picture of the occurrence and course of the disease. It is also important to clarify with the patient what ailments he previously suffered from, since neuropathic pain can progress against the background of certain pathological conditions. In addition to the interview, the doctor will also examine the patient and, if necessary, send him for the necessary tests.

Treatment of the disease

Treatment of neuropathic pain is a rather long and difficult process. The first thing that needs to be done is to treat the underlying pathology, against the background of which neuropathic pain manifested itself.

Treatment is complex and consists of:

• taking pharmaceuticals;
• application of psychotherapeutic methods;
• prescription of physiotherapeutic procedures.

Drug treatment is the most in an effective way relief from neuropathic pain. To treat this pathological condition ointments or patches with lidocaine are most effective. In owls local application With antidepressants it is possible to achieve a decrease in hypersensitivity. Pharmaceuticals also used to treat an illness that causes neuropathic pain.

Physiotherapy is prescribed to reduce pain. Thanks to acupuncture, therapeutic massage, laser exposure and magnetic therapy, it is possible to achieve not only a reduction in pain, but also improve blood circulation. But the most effective methods of treating this pathological condition are exercise therapy and yoga.

Treatment of neuropathic pain with folk remedies is absolutely useless, since the causes of origin are at the level of nerve endings. Self-medication is strictly prohibited, as it can lead to complete death of the nerve. The only possible treatment at home is taking herbal decoctions, which have a calming effect on the body as a whole. But resorting to this method without the consultation and approval of a doctor is undesirable.

It is worth noting that not in all cases medicine can help get rid of such a problem. This is due to the complex structure of nerves in the human body. IN in rare cases Medical intervention not only does not have any positive effect, but, on the contrary, can complicate the situation.

If, nevertheless, a person has suffered such a disease, then, in addition to the above-mentioned treatment methods, it will be useful for him:

• Spa treatment;
• treatment with lasers;
• physiotherapy;
• psychotherapy.

Prevention

There are not many preventative methods for neuropathic pain. This is due to the fact that to this day real reasons The manifestation of this type of pain has not been precisely studied. But still, there are several methods of prevention, which consist of:

Neuropathic pain syndrome. Neuropathic pain, unlike ordinary pain, which is a signaling function of the body, is not associated with dysfunction of any organ. This type of pain can make doing the simplest activities excruciating. Types: Neuropathic pain, like “ordinary” pain, can be acute or chronic. There are also other forms of pain: Moderate neuropathic pain in the form of burning and tingling. Most often felt in the extremities. It does not cause any particular concern, but it creates psychological discomfort in a person. Pressing neuropathic pain in the legs. It is felt mainly in the feet and legs, and can be quite pronounced. Such pain makes walking difficult and brings serious inconvenience to a person’s life. Short-term pain. It may last only a couple of seconds and then disappears or moves to another part of the body. Most likely caused by spasmodic phenomena in the nerves. Excessive sensitivity when the skin is exposed to temperature and mechanical factors. The patient experiences discomfort from any contact. Patients with this disorder wear the same familiar things and try not to change positions during sleep, since changing positions interrupts their sleep. Neuropathic pain can occur due to damage to any part of the nervous system (central, peripheral and sympathetic). I will list the main influencing factors for this pathology: Diabetes mellitus. This metabolic disease can cause nerve damage. This pathology is called diabetic polyneuropathy. It can lead to neuropathic pain of various types, mainly localized in the feet. Pain syndromes intensify at night or when wearing shoes. Herpes. The consequence of this virus may be postherpetic neuralgia. More often this reaction occurs in older people. Neuropathic post-herpes pain can last for about 3 months and is accompanied by severe burning in the area where the rash was present. There may also be pain from touching clothing and bedding to the skin. The disease disrupts sleep and causes increased nervous excitability. Spinal cord injury. Its consequences cause long-term pain symptoms. This is due to damage to the nerve fibers located in the spinal cord. This can be severe stabbing, burning and spasmodic pain in all parts of the body. Stroke. This serious brain injury causes great damage to the entire human nervous system. A patient who has undergone this disease, for a long time(from a month to a year and a half) may feel painful symptoms of a stabbing and burning nature in the affected side of the body. Such sensations are especially pronounced when in contact with cool or warm objects. Sometimes there is a feeling of freezing of the limbs. Surgical operations. After surgical interventions caused by the treatment of diseases of internal organs, some patients are bothered by discomfort in the suture area. This is due to damage to peripheral nerve endings in the area surgical intervention. Often such pain occurs due to removal of the mammary gland in women. Trigeminal neuralgia. This nerve is responsible for facial sensitivity. When it is compressed as a result of injury and due to expansion of the nearby blood vessel Intense pain may occur. It can occur when talking, chewing, or touching the skin in any way. More common in older people. Osteochondrosis and other diseases of the spine. Compression and displacement of the vertebrae can lead to pinched nerves and the appearance of pain of a neuropathic nature. Compression of the spinal nerves leads to the occurrence of radicular syndrome, in which pain can manifest itself in completely different areas body - in the neck, in the limbs, in the lumbar region, as well as in internal organs- in the area of ​​the heart and stomach. Multiple sclerosis. This damage to the nervous system can also cause neuropathic pain in different parts of the body. Radiation and chemical exposure. Radiation and chemical substances provide Negative influence on neurons of the central and peripheral nervous system, which can also be expressed in the occurrence of pain of a different nature and varying intensity. Neuropathic pain is characterized by a combination of specific sensory disturbances. The most characteristic clinical manifestation of neuropathy is a phenomenon called “allodynia” in medical practice. Allodynia is a manifestation of a pain reaction in response to a stimulus that healthy person does not cause pain. A neuropathic patient may experience severe pain from the slightest touch and literally from a breath of air. Allodynia can be: mechanical, when pain occurs when pressure is applied to certain areas skin or irritation with their fingertips; thermal, when pain manifests itself in response to a temperature stimulus. There are no specific methods for diagnosing pain (which is a subjective phenomenon). However, there are standard diagnostic tests that allow you to evaluate symptoms and, based on them, develop a therapeutic strategy. Serious help When diagnosing this pathology, the use of questionnaires to verify pain and its quantitative assessment will help. It will be very useful accurate diagnosis causes of neuropathic pain and identification of the disease that led to it. For the diagnosis of neuropathic pain in medical practice The so-called three “C” method is used - look, listen, correlate. look - i.e. identify and evaluate local violations pain sensitivity; listen carefully to what the patient says and note characteristic features in the description to them pain symptoms; correlate the patient's complaints with the results objective examination; It is these methods that make it possible to identify symptoms of neuropathic pain in adults. Treatment of neuropathic pain is often a lengthy process and requires a comprehensive approach. The therapy uses psychotherapeutic, physiotherapeutic and medicinal methods. Medication This is the main method in the treatment of neuropathic pain. Often, such pain cannot be relieved with conventional painkillers. This is due to the specific nature of neuropathic pain. Treatment with opiates, although quite effective, leads to tolerance to the drugs and can contribute to the formation of drug addiction. IN modern medicine Lidocaine (in the form of an ointment or patch) is most often used. The drug gabapentin and pregabalin are also used - effective medicines foreign production. Antidepressants are used together with these drugs - sedatives for the nervous system, reducing its hypersensitivity. In addition, the patient may be prescribed drugs that eliminate the consequences of the diseases that led to neuropathy. Non-drug Physiotherapy plays an important role in the treatment of neuropathic pain. IN acute phase diseases apply physical methods relief or reduction of pain syndromes. Such methods improve blood circulation and reduce spasmodic phenomena in the muscles. At the first stage of treatment, diadynamic currents, magnetic therapy, and acupuncture are used. In the future, physiotherapy is used that improves cellular and tissue nutrition - laser, massage, light and kinesitherapy (therapeutic movement). During the recovery period physical therapy is given great importance. Various relaxation techniques are also used to help eliminate pain. During the period of remission, patients are recommended active image life and regular health-improving gymnastics. Swimming has a positive effect hiking on fresh air. Treatment of neuropathic pain with folk remedies is not particularly popular. Patients are strictly prohibited from using traditional methods self-medication (especially heating procedures), since neuropathic pain is most often caused by inflammation of the nerve, and its heating is fraught with serious damage, including complete death. Herbal medicine (treatment with herbal decoctions) is acceptable, but before using any herbal remedy You should consult your doctor. Neuropathic pain, like any other, requires careful attention. Timely treatment will help avoid severe attacks of the disease and prevent its unpleasant consequences.

Description:

Neuropathic pain is a type of pain that, unlike ordinary pain, does not arise as a result of a reaction to physical damage, but as a result of pathological excitation of neurons in the peripheral or central nervous system responsible for the response to physical damage to the body (ordinary pain). Neuropathic pain experienced by 6–8% of the European population. Unfortunately, patients seek qualified medical care late, suffering for months. Meanwhile, in the last 20 years, new treatment methods have emerged that can successfully solve this medical problem. Pain is a signal that injury, inflammation or mechanical compression of a nerve has occurred in the body; it occurs when the peripheral pain receptors of the sensory nerves are irritated.

Symptoms:

Neuropathic pain - burning, cutting or shooting. May be paroxysmal or constant. Often accompanied by a sensation of “pins and needles”, increased sensitivity to touch and any movements. If with lumbar radiculitis the pain radiates to the leg, foot and fingers, and with cervical radiculitis it spreads along the arm, reaching the hand, then it also has a neuropathic component.
Painful memory. It is formed with constant damage to nerve fibers when pain signals are produced over a long period of time. In such cases, even minor stimuli - touch, heat, cold or stretching - are perceived as pain. People who have suffered for a long time chronic pain, often experience fear and hopelessness. They are prone to depression, can withdraw into themselves, and limit communication with friends and relatives.

Causes:

Signals arising from tissue damage (trauma, inflammation, pressure, heat, cold) are “read” by pain receptors (nociceptors) located on the skin, ligaments, muscles and internal organs. Pain impulses are transmitted along the nerves to the spinal cord, and from there to the brain, where they are recognized as pain.
In neuropathic pain, nerve damage itself stimulates such impulses. Main reasons - physical influences(pressure, overextension), toxic (alcohol), metabolic dysfunction (diabetes, vitamin deficiencies), viral infections (shingles) or inflammatory processes. Radicular pain can also be neuropathic when nerve roots are strangulated by a herniated disc.
Nerve damage leads to the development of neuropathic syndromes, the most common of which are discogenic and vertebrogenic lumbar and cervical radiculopathies (34.7% and 11.9%), diabetic polyneuropathy(10.6%), trigeminal nerve (5.8%), (4.1%).

Treatment:

For treatment the following is prescribed:

First of all, it is necessary to treat the underlying disease that led to the development of neuropathic pain (regulation of optimal blood glucose levels during diabetes mellitus, adequate antiviral therapy for herpes zoster, timely initiation of anti-inflammatory and decongestant treatment for cervico-brachial and lumbar radiculitis). It is recommended to start helping as early as possible so that memory blocks do not have time to form in the brain, reproducing this pain at the first symptoms and contributing to the development of persistent pain.
The main goal of therapy is to eliminate or reduce pain. A number of methods are used, not only medicinal ones. Sometimes a combination of several is required pharmacological drugs And non-drug methods treatment.
Conventional analgesics (aspirin, analgin and paracetamol) are ineffective. Anticonvulsants and antidepressants relieve neuropathic pain. Sometimes narcotic painkillers can help. Best result achieved by combining two or three drugs.

to therapy
Neuropathic pain is a pain syndrome caused by damage to the somatosensory nervous system due to the most various reasons(Table 1). The incidence in the population is 6-7%, and at neurological appointments patients with neuropathic pain account for 10-12%. Clinically, this type of pain is characterized by a complex of specific sensory disorders, which can be divided into two groups. On the one hand, these are positive symptoms (spontaneous pain, allodynia, hyperalgesia, dysesthesia, paresthesia), on the other - negative symptoms (hypoesthesia, hypalgesia). This type of pain can be difficult to treat and the pain may not always be completely relieved. Often, such patients have disturbed sleep, develop depression and anxiety, and decrease their quality of life. Many of them suffer for a long time before receiving adequate help. Most patients (about 80%) experience pain for more than a year before their first visit to a specialist. Treatment of the underlying disease (which is naturally unconditional) does not always lead to pain reduction. We often observe a dissociation between the severity of pain and the degree of damage to the nervous system. Unfortunately, many patients with neuropathic pain mistakenly take NSAIDs, which are ineffective for this type of pain. This is due to the fact that in neuropathic pain the main pathogenetic mechanisms are not the processes of activation of peripheral nociceptors, but neuronal and receptor disorders, peripheral and central sensitization.
In the treatment of neuropathic pain, it is best to use an integrated approach. Even within outpatient care, treatment can be initiated by several different methods. Absent today sufficient quantity evidence of the benefits of using conservative non-drug treatments (for example, physical therapy, physical exercise, transcutaneous electrical nerve stimulation). However, given the relative safety of these methods, in the absence of contraindications, the possibility of their use should not be excluded.
The most recognized treatment for neuropathic pain today is pharmacotherapy. The main drugs and their characteristics are given in Table 2.
For postherpetic neuralgia, it may first be prescribed local treatment lidocaine. It is believed that the action of lidocaine is based on blocking the movement of sodium ions through cell membrane neurons. This stabilizes the cell membrane and prevents the propagation of action potentials and consequently reduces pain. It should be borne in mind that the reduction of pain with local use of painkillers does not extend beyond the area and duration of contact with the affected area of ​​the body. This may be convenient for patients with a small area of ​​pain. Lidocaine 5% in patch or sheet form is indicated for the relief of pain associated with postherpetic neuralgia (PHN). Adverse reactions in the form of burning and erythema can be observed at the site of application with prolonged use.
For neuropathic pain of other origin, as well as in case of failure of treatment with lidocaine, it is recommended to begin oral monotherapy with pregabalin or gabapentin, a tricyclic antidepressant or a mixed serotonin-norepinephrine reuptake inhibitor. Of the listed drugs, pregabalin and gabapentin have the best tolerability. These drugs are characterized by an almost complete absence drug interactions and low incidence of adverse events. Both drugs have been shown to be effective in treating a variety of neuropathic pain conditions. However, compared to gabapentin, pregabalin, having linear pharmacokinetics and significantly higher bioavailability (90%), has a rapid positive dose-dependent effect: in the studies, a significant reduction in pain of more than 60% of the initial level was achieved within 1-3 days of treatment and persisted for throughout the course of treatment. The rapidity of pain reduction directly correlates with improved sleep and mood in these patients; the convenient dosing regimen of pregabalin also increases compliance in the treatment of these patients and promotes more rapid improvement quality of life. Pregabalin dosage is from 300 to 600 mg/day. showed to be most effective compared to placebo, significantly reducing pain and sleep disturbances. The drug can be taken before, during or after meals. When treating neuropathic pain, the starting dose may be 150 mg/day. in 2 doses. To obtain ++optimal therapeutic effect, the dose of pregabalin must be increased to 300 mg/day. starting from day 4 of therapy. If necessary, the dose is increased to the maximum (600 mg/day) after a 7-day interval. In accordance with experience with the use of the drug, if it is necessary to stop taking it, it is recommended to gradually reduce the dose over the course of a week. Pregabalin is not metabolized in the liver and does not bind to plasma proteins, so it has virtually no interaction with other drugs. Pregabalin is well tolerated. Most common adverse reactions are dizziness and drowsiness.
Tricyclic antidepressants are also effective but cheaper; however, with their use there is a higher likelihood of developing side effects. Moreover, they are relatively contraindicated in cardiovascular pathology(before prescribing tricyclic antidepressants, an ECG is recommended), orthostatic hypotension, urinary retention and angle-closure glaucoma, and should also be prescribed with caution to elderly patients. Of the available tricyclic antidepressants in Europe, preference is given to nortriptyline and desipramine, since their use is accompanied by fewer side effects. Newer mixed serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine and duloxetine) are considered to be less effective than tricyclic antidepressants, but at the same time they are better tolerated.
It is currently unknown whether failure of one drug predicts failure of another or all subsequent failures. drug therapy. If the first prescribed drug turned out to be ineffective or poorly tolerated by the patient, you should switch to alternative monotherapy with a first-line drug (Fig. 1). If all first-line drugs are ineffective or poorly tolerated, it is recommended to start monotherapy with tramadol or its combination with paracetamol or an opioid analgesic. Unfortunately, this is not always possible, since the prescription of opioid drugs is limited special requirements requirements for prescribing these drugs.
Due to the variety of pain mechanisms, treatment for each patient must be individualized taking into account the disease that caused the pain, as well as clinical features the pain syndrome itself. In addition, many factors should be taken into account, such as: general state patient, presence concomitant diseases(for example, concomitant depression or drug addiction/substance abuse, liver and kidney diseases, etc.), failure/success of previous therapy, as well as the availability of drugs in a pharmacy or hospital. During development individual approach To drug treatment, in addition to the direct analgesic effect, others must be taken into account positive effects the drug of choice (eg, reducing anxiety, improving sleep, mood and quality of life), as well as factors such as its tolerability and the potential for serious side effects. Patients with neuropathic pain require ongoing psychological support. Rational psychotherapy in this case can play a key role. Information about the causes of the disease, actual treatment prognoses and planned therapeutic activities is also extremely important for patients.
Treatment of neuropathic pain is a long process that requires regular monitoring of the patient’s health and implementation medical prescriptions. At the beginning of therapy Special attention Care should be taken to properly titrate the dose of drugs and monitor the possibility of drug interactions. During the treatment process, it is necessary to regularly inquire about how the patient complies with treatment regimens, decide on the need to continue taking the drug, and evaluate its effectiveness. Considering the long-term nature of therapy, it is necessary to monitor and, if possible, prevent the development of long-term adverse events (such as hepato- and gastro-toxicity, changes in the blood system, etc.) that occur while taking certain medications .
Before starting therapy, an explanatory conversation should be held with the patient and his relatives that the treatment can be long-term, and the reduction in pain will occur gradually. For neuropathic pain, even with the right treatment program, it is rarely possible to achieve 100% pain relief. Thus, the doctor must in a certain way form adequate expectations of the patient and his relatives regarding treatment. In a special study, it was shown that a decrease in pain intensity by 30% from the initial level according to VAS is assessed by the patients themselves as a satisfactory result. This figure should be kept in mind when assessing the effectiveness of the treatment and deciding whether to switch to another drug or add a new drug to the one already taken (rational polypharmacotherapy).
Table 3 summarizes the recommendations of the European Federation of Neurological Societies (EFNS) for the treatment of certain conditions associated with neuropathic pain. Experts from this federation analyzed all clinical trials on neuropathic pain recorded in the Cochrane Library (a database of evidence-based clinical trials) since 1966. As a result, studies with a high level of evidence were selected and based on them, European recommendations on pharmacotherapy.
Rational polypharmacotherapy
Pharmacotherapy in the treatment of neuropathic pain is the main treatment method. However, if, against the background of monotherapy with first-line drugs, it is not possible to completely relieve the pain syndrome, then the prescription of combination pharmacotherapy can increase the effectiveness of treatment with lower dosages of drugs and reduce the risk of developing side effects. This principle is called rational polypharmacotherapy. Many patients with neuropathic pain are forced to take multiple medications at the same time, despite the lack of evidence-based studies confirming the benefits of such combinations. Recently, information about the effectiveness of various combinations has begun to appear in the literature. known drugs. In one randomized, placebo-controlled trial, the combination of morphine and gabapentin was shown to be superior to either drug alone in terms of analgesic effect. Another study involving 11 patients with neuropathic pain refractory to gabapentin demonstrated the superiority of the combination of gabapentin and venlafaxine over gabapentin alone. Today there is an obvious need for further research to identify optimal effective combinations medications, selection of doses and the safest combinations, as well as to assess the pharmacoeconomic aspects of therapy.
Some aspects of pharmacotherapy
Before prescribing any new drug for the treatment of neuropathic pain, a careful analysis of the drugs already taken by the patient is necessary to exclude drug interactions. In the case of polypharmacotherapy, preference should be given to drugs that do not have known drug interactions (for example, pregabalin).
Currently, the potential for interaction between opioid analgesics and tricyclic antidepressants, causing serious adverse events in case of overdose. If such a combination is used, the benefits and risks of this prescription must be carefully weighed. SSRIs (eg, fluoxetine or paroxetine) and SNRIs (eg, duloxetine) should not be co-administered as they are metabolized by cytochrome P450, which increases the risk of adverse reactions.
Most tricyclic antidepressants anticonvulsants and opioid analgesics have a depressant effect on the central nervous system. To reduce the severity of these and other side effects, gradual titration should be used to achieve an effective dose, starting from the minimum (for example, 1/4 tablet of amitriptyline containing 25 mg) to the maximum tolerated dose over several weeks. In this case, the doctor and patient must understand that pain relief will be gradual. Because tricyclic antidepressants and carbamazepine are rapidly metabolized in some patients, monitoring of drug plasma levels is required before it is safe to further increase the dose if there is no analgesic effect at the lowest dose.
Differentiated therapy
pain syndromes
Analysis of the pain syndrome from the point of view of its pathophysiological mechanisms (nociceptive, neuropathic, mixed) turned out to be very important, primarily from the point of view of treatment. If the doctor assesses the pain as nociceptive, then by the best means Its treatment will be simple analgesics and NSAIDs. If the pain is neuropathic or there is a neuropathic component, then the drugs of choice are anticonvulsants (pregabalin), antidepressants, opioid analgesics and lidocaine, the features of which were discussed above (Fig. 2). In the case of mixed pain syndromes, it is possible combination therapy with the choice of means depending on the representation of nociceptive and neuropathic components (Fig. 3).
Thus, treatment of neuropathic pain currently remains challenging task. The principles and treatment algorithms presented above can help the doctor carry out the most effective and safe treatment patients with neuropathic pain syndrome. In the future, the success and prospects of treatment are associated with the development of drugs that affect specific pathophysiological mechanisms of this syndrome.

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