neuropathic pain. Neuropathic pain treatment with folk remedies

Painful sensations, regardless of their localization, bring a lot of uncomfortable sensations to a person. In no case should they be ignored, since they are a signal of 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 such a phenomenon can bring a person to the development of severe depression. But what is such a pathology, why does it develop and how can its therapy be carried out?

How does neuropathic pain manifest itself? Symptoms

Neuropathic pain can present in a variety of ways. In certain cases, it leads to permanent pain, causes a feeling of tingling, as well as burning. Pain in this case is localized in the limbs, most often in the area of ​​​​the fingers. Most often, such pains do not differ in a high degree of intensity and do not bother a person much, but in certain cases they are characterized by strength and duration.

Also, neuropathic pains can be compressive or tightening in nature, they are fixed in the legs, namely in the feet or lower legs, but they can also affect other parts of the body. Such a symptom significantly interferes with normal life and is often accompanied by other pains, it is difficult to correct.

Neuropathic pain is sometimes transient or acute, and may be localized to the extremities and fingers. In this case, the symptom may be felt in the finger on one hand for several seconds, and then move to another part of the body. It may well be that such a phenomenon is provoked by a spasm of nerve endings and subsequent signal transmission to the brain.

Sometimes neuropathic pain manifests itself hypersensitivity for all sorts of touches. A proportion of patients even twitch at the slightest impact, they try to wear only soft and most imperceptible clothes, 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, often such a problem is localized in the limbs, and especially in the fingers. The patient may feel that he, as it were, has frostbite on his arm or leg, and in certain cases he is worried about numbness.

Why does neuropathic pain occur? Causes

Neuropathic pain can be triggered by herpes zoster, this complication most often develops in adulthood. In addition, such a pathology can develop against the background of diabetes mellitus, in which case an elevated glucose level causes 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 sutures. In certain cases, their cause lies in neuralgia trigeminal nerve and back problems. Among other things, sometimes they are provoked by amputation, the development of multiple sclerosis and AIDS. There is evidence that such a phenomenon sometimes develops as a result of chemical or radiation exposure.

What about those diagnosed with neuropathic pain? Treatment of the condition

Therapy of neuropathic pain should start exclusively with the identification of the causes of the development of such a symptom. Only by finding out the factor that caused the pathology, you can 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. In the presence of diabetes, you need to carefully monitor the level of sugar in the blood.

If we talk about the elimination of pain, which is certainly the most important thing for each 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 unpleasant symptoms are of a completely different nature. Quite often, doctors prescribe anticonvulsant drugs to patients, which can relieve tension from the muscles, as well as from the vessels.

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

In the presence of inflammatory processes in the body, the use of non-steroidal anti-inflammatory medicinal formulations will benefit.

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

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

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

Neuropathic pain is a pathological condition that manifests itself in the restructuring of somatosensory signal processing of the body, 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 happen as a result of a pinched nerve fiber or a violation of its nutrition.

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

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

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 elevated content sugar in the bloodstream. Half of the people who are prone to diabetes suffer from neuropathic pain. In them, it is usually manifested by a feeling of tingling and burning in the feet. Unpleasant sensations are aggravated during sleep or when wearing tight shoes;
• herpes outbreak. Pain usually appears after shingles. It is observed most often in the elderly. Duration - up to three months. Characterized severe discomfort and increased sensitivity in the place where the rash was, sleep disturbances. It also sometimes occurs when clothes or bedding are touched on the body;
• various spinal cord injuries. These injuries often result in damage to the nerves in spinal cord, and are directly related to this type of pain. Pathological process accompanied by tingling all over the body;
• . Neuropathic pain may appear several years after the attack. Patients usually feel constant cold hands The cause of the occurrence is damage to the nerves of the brain;
• surgical intervention. The feeling of tingling and numbness at the site of the localization of the seam constantly worries such people;
• back injury. In this case, such a pathological condition manifests itself in the form of a shooting pain syndrome 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 often have to rest on their elbows or keep their hands on weight;
• radiation;

Varieties

As well as ordinary, neuropathic pain can occur in acute or chronic form. But there are other types:

• moderate - tingling is felt in the arms or legs;
• pressing - the main place of manifestation - the feet or lower legs. Often makes it difficult to walk and brings discomfort to a person’s life;
• short-term - the duration is 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 occurrence. In addition to a superficial feeling, 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;
• a decrease in the 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 survey of the patient. This is necessary to draw up a complete picture of the onset and course of the disease. It is also important to clarify with the patient what ailments he had previously had, since neuropathic pain may progress against the background of some pathological conditions. In addition to the survey, the doctor will also examine the patient and, if necessary, send him for the necessary tests.

Treatment of the disease

The treatment of neuropathic pain is a rather lengthy and difficult process. The first thing to do is to treat the underlying pathology, against which the neuropathic pain manifested itself.

Treatment is complex and consists of:

• taking pharmaceuticals;
• application of psychotherapeutic methods;
• prescribing physiotherapy.

Medical treatment is the most in an efficient way relief from neuropathic pain. For the treatment of this pathological condition lidocaine ointments or patches are most effective. in owls topical application with antidepressants it is possible to achieve a decrease in hypersensitivity. Pharmaceuticals also used to treat the disease that caused the manifestation of neuropathic pain.

Physiotherapy is prescribed to reduce pain. Thanks to acupuncture, therapeutic massage, laser exposure and magnetotherapy, one can achieve not only a reduction in the manifestation of 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 the complete death of the nerve. The only possible treatment at home is the use of herbal decoctions, which have a calming effect on the body as a whole. But resorting to this method without the advice 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 the nerves in the human body. IN rare cases medical intervention not only does not bring any positive effect, but, on the contrary, can complicate the situation.

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

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

Prevention

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

Neuropathic pain syndrome. Neuropathic pain, unlike ordinary pain, which is a signal function of the body, is not associated with disorders in the functioning of any organ. This kind of pain can make even the simplest of tasks excruciating. Types: Neuropathic pain, like “ordinary” pain, can be acute and chronic. There are also other forms of pain: Moderate neuropathic pain in the form of burning and tingling. Most often felt in the limbs. It does not cause 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, can be quite pronounced. Such pain makes it difficult to walk and brings serious inconvenience to a person's life. Short term pain. It may last only a couple of seconds, and then disappear or move to another part of the body. Most likely caused by spasmodic phenomena in the nerves. Excessive sensitivity when exposed to the skin of temperature and mechanical factors. The patient experiences discomfort from any contact. Patients with such a disorder wear the same habitual things and try not to change positions during sleep, as a change in position interrupts their sleep. Pain of a neuropathic nature can occur due to damage to any parts of the nervous system (central, peripheral and sympathetic). I will list the main factors of influence for this pathology: Diabetes mellitus. This metabolic disease can lead to nerve damage. This pathology is called diabetic polyneuropathy. It can lead to neuropathic pain of various nature, mainly localized in the feet. Pain syndromes are aggravated at night or when wearing shoes. Herpes. The consequence of this virus may be postherpetic neuralgia. Most 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 the skin of clothing and bedding. The disease disrupts sleep and causes increased nervous excitability. spinal cord injury. Its effects cause long-term pain symptoms. This is due to damage to the nerve fibers located in the spinal cord. It can be strong stabbing, burning and spasmodic pain in all parts of the body. Stroke. This severe brain damage causes great damage to the entire human nervous system. The patient who has undergone this disease, for a long time(from a month to a year and a half) can feel pain 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 extremities. Surgical operations. After surgical interventions caused by the treatment of diseases of internal organs, some patients are disturbed 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 the removal of the mammary gland in women. Trigeminal neuralgia. This nerve is responsible for facial sensation. When it is compressed as a result of trauma and due to the 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 neuropathic pain. Compression of the spinal nerves leads to the occurrence of a radicular syndrome, in which pain can manifest itself in a completely different areas bodies - in the neck, in the limbs, in the lumbar region, as well as in internal organs- in the region of the heart and stomach. Multiple sclerosis. This lesion of the nervous system can also cause neuropathic pain in different parts of the body. Radiation and chemical exposure. Radiation and chemical substances render Negative influence on the neurons of the central and peripheral nervous system, which can also be expressed in the occurrence of pain sensations of a different nature and intensity. Neuropathic pain is characterized by a combination of specific sensory disturbances. The most characteristic clinical manifestation of neuropathy is a phenomenon referred to in medical practice as "allodynia". 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 with pressure on certain areas skin or irritated by their fingertips; thermal, when pain manifests itself in response to a thermal stimulus. Certain methods for diagnosing pain (which is a subjective phenomenon) do not exist. However, there are standard diagnostic tests that can be used to evaluate symptoms and develop a therapeutic strategy based on them. Serious help when diagnosing this pathology, the use of questionnaires for pain verification and its quantitative assessment will have. 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 method of three "C" is used - look, listen, correlate. look - i.e. identify and evaluate local violations pain sensitivity; listen carefully to what the patient says and note characteristics in their description pain symptoms; correlate the patient's complaints with the results objective examination; It is these methods that make it possible to identify the symptoms of neuropathic pain in adults. The treatment of neuropathic pain is often a lengthy process and requires an integrated approach. In therapy, psychotherapeutic methods of influence, physiotherapy and medication are used. Medication This is the main technique in the treatment of neuropathic pain. Often this pain is not relieved by conventional painkillers. This is due to the specific nature of neuropathic pain. Opiate treatment, although quite effective, leads to drug tolerance and may contribute to the formation of drug addiction. IN modern medicine most commonly used is lidocaine (in the form of an ointment or patch). Gabapentin and pregabalin are also used. effective medicines foreign production. Together with these drugs, antidepressants are used - sedatives for the nervous system, reducing its hypersensitivity. In addition, the patient may be prescribed drugs that eliminate the effects of diseases that led to neuropathy. Non-pharmacological 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, magnetotherapy, and acupuncture are used. In the future, physiotherapy is used that improves cellular and tissue nutrition - exposure to a laser, massage, light and kinesitherapy (therapeutic movement). During the recovery period physiotherapy exercises is given great importance. Various relaxation techniques are also used to help relieve pain. During remission, patients are advised active image life and regular health 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 folk methods self-treatment (especially warming procedures), since neuropathic pain is most often caused by inflammation of the nerve, and its heating is fraught with serious damage up to complete death. Phytotherapy (treatment with herbal decoctions) is acceptable, but before using any herbal remedy you should consult with your doctor. Neuropathic pain, like any other, requires careful attention. Timely treatment will help to 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 that are responsible for the reaction to physical damage to the body (normal 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 methods of treatment have appeared that can successfully solve this medical problem. Pain is a signal that an injury, inflammation or mechanical compression of a nerve has occurred in the body; it appears when the peripheral pain receptors of sensory nerves are irritated.

Symptoms:

Neuropathic pain - burning, cutting or shooting. May be intermittent or permanent. Often accompanied by a feeling of "goosebumps", increased sensitivity to touch and any movements. If with lumbar sciatica pain radiates to the leg, foot and fingers, and with cervical pain 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, warmth, cold, or stretching - are perceived as pain. People suffering from chronic pain often experience fear and hopelessness. They are prone to depression, can withdraw into themselves, limit communication with friends and relatives.

Causes of occurrence:

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, 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, beriberi), viral infections (shingles), or inflammatory processes. Radicular pain can also be neuropathic when nerve roots infringed 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 radiculopathy (34.7% and 11.9%), diabetic polyneuropathy(10.6%), trigeminal nerve (5.8%), (4.1%).

Treatment:

For treatment appoint:

First of all, it is necessary to treat the underlying disease that led to the development of neuropathic pain (regulation of the optimal level of glucose in the blood during diabetes, adequate antiviral therapy with herpes zoster, timely anti-inflammatory and anti-edematous treatment for cervical-brachial and lumbar sciatica). It is recommended to start help 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 the elimination or reduction of pain. A number of methods are used, not only medicinal ones. Sometimes combinations of several are required. pharmacological preparations And non-drug methods treatment.
Conventional analgesics (aspirin, analgin and paracetamol) are ineffective. Neuropathic pain is relieved by anticonvulsants and antidepressants. Sometimes narcotic pain relievers can help. Best result achieved with a combination of two or three drugs.

to therapy
Neuropathic pain is a pain syndrome caused by damage to the somatosensory nervous system due to the most different reasons(Table 1). The frequency of occurrence in the population is 6-7%, and at neurological appointments, patients with neuropathic pain are 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 hand, negative symptoms (hypesthesia, hypalgesia). This type of pain syndrome can be difficult to treat, and it is not always possible to completely stop the pain syndrome. Often, such patients have sleep disturbances, depression and anxiety develop, and quality of life decreases. 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. The treatment of the underlying disease (which is naturally unconditional) does not always lead to a reduction in pain. Often we observe a dissociation between the severity of pain and the degree of damage to the nervous system. Alas, 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 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 the framework of outpatient care, treatment may be initiated by several different methods. Missing today enough evidence for the benefit of conservative non-pharmacological treatments (eg, physical therapy, 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 in the treatment of neuropathic pain today is pharmacotherapy. The main drugs and their characteristics are shown in table 2.
In 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 the action potential and reduces pain accordingly. It should be borne in mind that the reduction of pain with topical application 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 distribution. Lidocaine 5% in patch or plate form is indicated for pain relief in postherpetic neuralgia (PHN). Adverse reactions in the form of burning and erythema can be observed at the site of sticking with prolonged use.
For neuropathic pain of other origins, as well as in case of failure of treatment with lidocaine, it is recommended to start oral monotherapy with pregabalin or gabapentin, a tricyclic antidepressant, or a mixed serotonin-norepinephrine reuptake inhibitor. Of these drugs, pregabalin and gabapentin are best tolerated. These drugs are characterized by the almost complete absence drug interactions and low incidence of adverse events. Both drugs have been shown to be effective in the treatment of a variety of neuropathic pain. However, compared with gabapentin, pregabalin, having a linear pharmacokinetics and a significantly higher bioavailability (90%), has a rapid positive dose-dependent effect: in the studies, a significant reduction in pain of more than 60% from the initial level was achieved within 1-3 days of treatment and persisted for throughout the course of treatment. The speed of pain reduction directly correlates with the improvement of sleep and mood in these patients, the convenient dosing regimen of pregabalin also improves compliance in the treatment of these patients and contributes to more rapid improvement quality of life. The dosage of pregabalin is from 300 to 600 mg/day. proved to be the most effective compared to placebo, significantly reducing pain and sleep disturbances. The drug can be taken before, during or after meals. In the treatment of neuropathic pain, the starting dose may be 150 mg / day. in 2 doses. To obtain ++ optimal therapeutic effect, the dose of pregabalin should be increased to 300 mg / day. starting from day 4 of therapy. If necessary, the dose is increased to a maximum (600 mg / day) after a 7-day interval. In accordance with the experience of using the drug, if it is necessary to stop taking it, it is recommended to gradually reduce the dose over a week. Pregabalin is not metabolized in the liver and does not bind to plasma proteins, so it has little to no interaction with other drugs. Pregabalin is well tolerated. The most frequent adverse reactions are dizziness and drowsiness.
Tricyclic antidepressants are also effective but less expensive; however, they are more likely to develop side effects. Moreover, they are relatively contraindicated in cardiovascular pathology(before the appointment of tricyclic antidepressants, an ECG is recommended), orthostatic hypotension, urinary retention and angle-closure glaucoma, and should be used with caution in elderly patients. Of the available tricyclic antidepressants in Europe, nortriptyline and desipramine are preferred because they are associated with fewer side effects. More recent mixed serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine and duloxetine) are considered to be less effective than tricyclic antidepressants, but are also better tolerated.
To date, it is not known whether the failure of one drug is a predictor of the failure of another or of the entire subsequent one. drug therapy. In the event that the first prescribed drug was ineffective or poorly tolerated by the patient, one should switch to alternative monotherapy with a first-line drug (Fig. 1). If all first-line drugs have been ineffective or poorly tolerated, it is recommended to start tramadol monotherapy or its combination with paracetamol or an opioid analgesic. Unfortunately, this is not always possible as prescription of opioids is limited. special requirements for prescribing these drugs.
Due to the variety of pain mechanisms, the treatment of each patient should 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(e.g. comorbid depression or drug/substance abuse, liver and kidney disease, etc.), failure/success of prior therapy, and drug availability at the pharmacy or hospital. When developing individual approach To drug treatment, in addition to the immediate analgesic effect, other positive effects drug of choice (eg, reduced anxiety, improved sleep, mood, and quality of life), as well as factors such as tolerability and potential for serious side effects. Patients with neuropathic pain need constant psychological support. Rational psychotherapy in this case can play a key role. Information about the causes of the disease, about the real prognosis of treatment and planned therapeutic activities is also extremely important for patients.
The treatment of neuropathic pain is a long process that requires regular monitoring of the patient's health and implementation medical appointments. At the beginning of therapy Special attention should pay attention to the correct titration of the dose of drugs and monitor the possibility of developing drug interactions. In the course of treatment, it is required to regularly be interested in how the patient complies with the treatment regimen, decide whether it is necessary to continue taking the drug and evaluate its effectiveness. Taking into account the long-term therapy, it is necessary to monitor and, if possible, prevent the development of long-term adverse events (such as, for example, hepato- and gastro-toxicity, changes in the blood system, etc.) that occur while taking certain drugs .
Before starting therapy, an explanatory conversation should be held with the patient and his relatives that the treatment can be long, and the pain will decrease gradually. With 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 about the 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 evaluating the effectiveness of ongoing treatment and deciding whether to switch to another drug or add a new drug to an already taken one (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. The experts of this federation analyzed all clinical research in neuropathic pain registered in the Cochrane Library (database of evidence-based clinical studies) since 1966. As a result, studies with a high level of evidence were selected, and on their basis European recommendations on pharmacotherapy.
Rational polypharmacotherapy
Pharmacotherapy in the treatment of neuropathic pain is the main method of treatment. However, if against the background of monotherapy with first-line drugs it is not possible to completely stop the pain syndrome, then the appointment of combined pharmacotherapy can increase the effectiveness of treatment at 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 drugs at the same time, despite the lack of evidence-based studies supporting the benefits of such combinations. Recently, information began to appear in the literature about the effectiveness of various combinations already known medicines. 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 in 11 patients with neuropathic pain refractory to gabapentin demonstrated the superiority of the combination of gabapentin and venlafaxine over gabapentin alone. Today, the need for further research is obvious in order to identify the optimal effective combinations drugs, 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 review of drugs already taken by the patient is necessary in order to exclude drug interactions. In the case of polypharmacotherapy, preference should be given to drugs with no known drug interactions (eg, pregabalin).
A potential interaction between opioid analgesics and tricyclic antidepressants has now been described, causing serious adverse events with an overdose. In the case of using such a combination, it is necessary to carefully weigh the benefits and risks of this appointment. SSRIs (eg, fluoxetine or paroxetine) and SNRIs (eg, duloxetine) should not be administered concomitantly because they are metabolized by cytochrome P450, which increases the risk of adverse reactions.
Most tricyclic antidepressants anticonvulsants and opioid analgesics has a depressant effect on the central nervous system. In order to reduce the severity of these and other side effects in the process of achieving an effective dose, it is necessary to use gradual titration, 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 physician and patient must be aware that pain relief will be gradual. Since tricyclic antidepressants and carbamazepine are rapidly metabolized in some patients, monitoring of plasma levels of the drug is required before it is safe to further increase the dose in the absence of analgesic effect at the minimum dose.
Differential Therapy
pain syndromes
The 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 best means for its treatment there 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 presence of nociceptive and neuropathic components (Fig. 3).
Thus, the treatment of neuropathic pain currently remains challenging task. The principles and algorithms of treatment presented above can help the doctor to 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 act on specific pathophysiological mechanisms of this syndrome.

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