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Clinical practice guideline for neuropathic pain
 

Clinical practice guideline for neuropathic pain

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แนวทางเวชปฏิบัติภาวะปวดเหตุพยาธิสภาพประสาท ...

แนวทางเวชปฏิบัติภาวะปวดเหตุพยาธิสภาพประสาท
(Clinical practice guideline for neuropathic pain),

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http://www.pmh.go.th/index.php?option=com_content&view=article&id=1719:-clinical-practice-guideline-for-neuropathic-pain-&catid=50:km&Itemid=115

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    Clinical practice guideline for neuropathic pain Clinical practice guideline for neuropathic pain Document Transcript

    • ·π«∑“߇«™ªØ‘∫—µ‘ ¿“«–ª«¥‡Àµÿ欓∏‘ ¿“æª√– “∑ (Clinical Practice Guideline for Neuropathic Pain) æ.». 2551 ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‚¥¬§«“¡√à«¡¡◊Õ®“° √“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬  ¡“§¡ª√– “∑«‘∑¬“·Ààߪ√–‡∑»‰∑¬ «‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√å§√Õ∫§√—«·Ààߪ√–‡∑»‰∑¬ °√¡æ—≤π“·æ∑¬å·ºπ‰∑¬·≈–·æ∑¬å∑“߇≈◊Õ° °√–∑√«ß “∏“√≥ ÿ¢  π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘
    • ·π«∑“߇«™ªØ‘∫—µ‘ ¿“«–ª«¥‡Àµÿ欓∏‘ ¿“æª√– “∑ (Clinical Practice Guideline for Neuropathic Pain) æ.». 2551 ISBN: 978-974-598-056-3 ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‚¥¬§«“¡√à«¡¡◊Õ®“° √“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬  ¡“§¡ª√– “∑«‘∑¬“·Ààߪ√–‡∑»‰∑¬ «‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√å§√Õ∫§√—«·Ààߪ√–‡∑»‰∑¬ °√¡æ—≤π“·æ∑¬å·ºπ‰∑¬·≈–·æ∑¬å∑“߇≈◊Õ° °√–∑√«ß “∏“√≥ ÿ¢  π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘
    • ·π«∑“߇«™ªØ‘∫—µ‘ ¿“«–ª«¥‡Àµÿ欓∏‘ ¿“æª√– “∑ ·π«∑“߇«™ªØ‘∫—µ‘ (Clinical Practice Guideline for Neuropathic Pain) ¿“«–ª«¥‡Àµÿ欓∏‘ ¿“æª√– “∑ æ.». 2551 ISBN: 978-974-598-056-3 (Clinical Practice Guideline for Neuropathic Pain) æ.».่อหนั2551 ชื งสือ ®—¥∑”‚¥¬ ISBN: 978-974-598-056-3 จัดทำโดย ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬ ‚¥¬§«“¡√à«¡¡◊Õ®“° √“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬åÕÕ√å‚∏ªî¥‘° å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ √“™«‘ ¬“≈— ¬·æ∑¬å Àà ª√–‡∑»‰∑¬  ¡“§¡°“√»÷√“™«‘∑∑¬“≈—ËÕ°ÿ»—¡≈“√·æ∑¬å··Ààßߪ√–‡∑»‰∑¬ ª√–‡∑»‰∑¬ °…“‡√◊ ¬¬ß§«“¡ª«¥·Ààß ‚¥¬§«“¡√à ¡¡◊Õ®“°  ¡“§¡ª√– “∑«‘∑«¬“·Ààߪ√–‡∑»‰∑¬ «‘∑√“™«‘·æ∑¬å‡¬Õ“¬ÿบสนุนโดยߪ√–‡∑»‰∑¬ ¬“≈—¬ ∑¬“≈— «™»“ µ√å§√Õ∫§√—«·Ààߪ√–‡∑»‰∑¬ สบั √·æ∑¬å·Àà °√¡æ—√“™«‘∑¬“≈—·¬·æ∑¬åÕÕ√å‚∏ªî¥‘° åÕÀàߪ√–‡∑»‰∑¬ ≤π“·æ∑¬å ºπ‰∑¬·≈–·æ∑¬å∑“߇≈◊ ·° °√–∑√«ß “∏“√≥ ÿ¢ √“™«‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√åøóôπøŸ·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬ √“™«‘∑¬“≈—¬°ÿ¡“√·æ∑¬å·Ààߪ√–‡∑»‰∑¬  π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘  ¡“§¡ª√– “∑«‘∑¬“·Ààߪ√–‡∑»‰∑¬ «‘∑¬“≈—¬·æ∑¬å‡«™»“ µ√å§√Õ∫§√—«·Ààߪ√–‡∑»‰∑¬ °√¡æ—≤π“·æ∑¬å·ºπ‰∑¬·≈–·æ∑¬å∑“߇≈◊Õ° °√–∑√«ß “∏“√≥ ÿ¢ ISBN: 978-974-598-056-3 พิมพ์ค ้งที่ 1  π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—รั°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘ ธันวาคม 2551 จำนวนพิมพ์ 4,000 เล่ม พิมพ์ที่ บียอนด์ เอ็นเทอร์ไพรซ์, กรุงเทพฯ
    • Neuropathic pain ” “ “ ” (general practitioners) “ ” . . ก
    • 1. . . 2. . . 3. . . . 4. . . 5. . . 6. . . 7. . 8. . . 9. . . 10. . . 11. . 12. . 13. . . 14. . 15. . ข
    • สารบัญ คำนำ รายนามคณะผู้จัดทำ ข้อแนะนำการใช้ CPG วิธีการสืบค้นข้อมูล บทที่ 1 บทนำ 1.1 ลักษณะอาการปวดเหตุพยาธิสภาพประสาท 1.2 ระบาดวิทยา บทที่ 2 การวินิจฉัย เครื่องมือ และวิธีติดตามภาวะปวดเหตุพยาธิสภาพประสาท บทที่ 3 การรักษาภาวะปวดเหตุพยาธิสภาพประสาท 3.1 การรักษาโดยการใช้ยา 3.2 การรักษาโดยการผ่าตัด 3.3 การรักษาโดยเวชศาสตร์ฟื้นฟู การแพทย์ผสมผสาน และ การแพทย์ทางเลือก บทที่ 4 การวินิจฉัย และรักษาภาวะปวดเหตุพยาธิสภาพประสาทในโรคที่จำเพาะ 4.1 Diabetic peripheral neuropathy 4.2 Post herpetic neuralgia 4.3 Trigeminal neuralgia 4.4 Phantom limb pain 4.5 Central pain 4.6 อื่นๆ บทที่ 5 เกณฑ์การส่งต่อผู้ป่วย ภาคผนวก 1 คุณภาพหลักฐาน (Quality of evidence) ภาคผนวก 2 หลักการกำหนดน้ำหนักคำแนะนำ ภาคผนวก 3 แนวทางการใช้ระดับหลักฐานประกอบการกำหนดน้ำหนักคำแนะนำ ภาคผนวก 4 ลักษณะของความปวดและการตรวจร่างกาย ภาคผนวก 5 เครื่องมือที่ใช้ในการวินิจฉัยและคัดกรอง ภาคผนวก 6 แบบสอบถาม Thai DN4 บรรณานุกรมและเอกสารแนะนำเพิ่มเติม ค หน้า ก ข ง ฉ 1 1 2 3 7 7 12 15 20 20 22 23 24 25 26 27 28 29 32 33 35 36 37
    • CPG CPG ++ CPG CPG (Strength of Recommendation) (cost effective) “ + +/- “ ” “ ” - -- ” “ ” “ ” (Classification of references) Level of evidence A systematic review randomized, controlled clinical trials randomized, controlled clinical trials Level of evidence B systematic review controlled clinical study controlled clinical study ( nonrandomized, controlled trial, cohort study, case-control study, cross sectional study) ง
    • randomized, controlled clinical trials randomized, controlled clinical trials systematic review randomized, controlled clinical trials randomized, controlled clinical trials Level of evidence C systematic review descriptive study descriptive study systematic review controlled clinical study controlled clinical study controlled clinical trials Level of evidence D (consensus) : Level of evidence ( . .- . . 2544) 18 จ 6
    • / Medline, Cochrane library, EMBASE 1966 2008 neuropathic pain, epidemiology, assessment, treatment, diagnosis, guideline, rehabilitation, complementary medicine, alternative medicine, acupuncture, central pain, post herpetic neuralgia, trigeminal neuralgia, diabetic peripheral neuropathy key articles ฉ
    • 1 1.1 Neuropathic pain somatosensory system (lancinating) (burning) (pins and needles) (itching) (paresthesia) (stimulus- independent pain spontaneous pain) (stimulus- dependent pain stimulus-evoked pain) (tingling) allodynia hyperalgesia Neuropathic pain neuropathic pain HIV neuropathic pain (mixed pain) neuropathic pain neuropathic pain diabetic neuropathy, multiple sclerosis Association for the Study of Pain “ neuropathic pain neuropathic pain neuropathic pain . . 1994 International neuropathic pain ”1 somatosensory pathways spino-thalamocortical system 1 
    • “ ” 2 neuropathic pain neuropathic pain . . 2007 2nd Congress of Neuropathic Pain “ somatosensory system” (Pain arising as a direct consequences of disease affecting the somatosensory system)3 (plasticity) neuropathic pain 4 (hyperexcitability) neuropathic pain 1.2 neuropathic pain multiple sclerosis post herpetic neuralgia spinal cord injury post mastectomy syndrome amputation pain sciatica neuropathic pain 6.8-8.25, 6 phantom pain low back 37.8-48 7, 8 369 herpetic neuralgia 10-1510 pain 54.712 stroke pain 813 multiple sclerosis 13- 38 15, 16, 17 neuropathic pain 18 syndrome 20 Neuropathic pain neuropathic pain21, 22  2 post low back post 16-2611 27.514 post mastectomy 19 20
    • 2 neuropathic pain (pathognomonic sign) neuropathic pain (neuroanatomy) ( 2.1 nociceptive, neuropathic, psychogenic neuropathic pain 2.1) 
    • 2.1 ( ( DN4 6) DN4 4, 5 4) ( 6) Thai + 1. 2. ++ ++ 3. ++ 4. , , 5. 6. + , 1 3-6 1 ++ + + 2 Neuropathic pain ( visual analog scale neuropathic pain ) numerical rating scale  4 ++ +/+
    • NEUROPATHIC PAIN Possible History of relevant disease or lesion in the nervous system Pain in neuroanatomical area Probable Decreased sensibility in painful area Definite Document of nerve lesion Decreased sensibility in painful area History of relevant disease or lesion in the nervous system Pain in neuroanatomical area History of relevant disease or lesion in the nervous system Pain in neuroanatomical area neuropathic pain1 2.1 neuropathic pain neuropathic pain ( 2.1) Neuropathic Pain Scale (NPS)2, Neuropathic Pain Questionnaire (NPQ)3, NPQ short form4, Neuropathic Pain Symptom Inventory (NPSI)5, ID LANSS Pain Scale9 ( 5) Pain6, DN47, PainDetect8 6) neuropathic pain DN410 ( Thai DN4 (quantitative) (qualitative) spontaneous ongoing pain, spontaneous paroxysmal pain, paresthesia (evoked pains) allodynia dysesthesia hyperalgesia 1. Visual analogue scale (VAS) 11 VAS 10 5 
    • ( 2.2 A) 2. Numerical rating scale (NRS) worst possible pain) ( 2.2 B) 3. Verbal rating scales (VRS) 2.2 C) 4. Wong-Baker faces pain rating scale 3 11-point Likert scale (0 = no pain, 10 = ( numerical rating scale 2.2 D) ( A B 0 C 1-3 0 1 2 3 7-10 4-6 4 5 6 7 8 9 10 D 2.2  A: Visual analogue scale (VAS), B: Numerical rating scale (NRS), C: Verbal rating scales (VRS), D: Wong-Baker faces pain rating scale
    • ( 2.3) 2.3 Quantitative Sensory Testing (QST) allodynia hyperalgesia 
    • 
    • * ?A first-line drug first-line drug 1 ?B 1) ( first-line ?C ( second-line 3.1) first-line drug * Average pain score B Average pain score C Average pain score 4-8 A VAS VAS VAS NRS NRS NRS < 3/10 > 4/10 30% 4-8 
    • 3.1 neuropathic pain 1. First-line medications 1.1 Tricyclic antidepressants Amitriptyline - Enhance descending inhibitory pain pathway 10-75 ./ ++ -- + - 75 ./ ) - -- + ++ 200-1200 ./ + - 300-1800 ./ + - 10-25 . 25 . 1-2 Nortriptyline Imipramine 1.2 Calcium channel 2 1 ligands - Gabapentin Block 2 subunit of calcium channel 1 , , anticholinergic, anticholinergic* 10- ( , 300-3600 ./ 100300 . 300 3-7 100. 2-4 1.3 Sodium channel blockers Carbamazepine - * 10 Oxcarbazepine Block sodium channel anticholinergic 10
    • 3.1 neuropathic pain 2. Second-line medications 2.1 Tramadol 50-400 -Weak agonist ./ - -Enhance descending inhibitory pain pathway agonist 2.2 Oral morphine - ( ) + SSRIs SNRIs - +/- SSRIs SNRIs TCAs + +/- tramadol 2.3 Methadone - agonist NMDA antagonist + +/- tramadol morphine 2.4 Pethidine neuropathic pain agonist 2.4 Selective serotonin and norepinephrine reuptake inhibitors (SNRIs) Venlafaxine 75-150 ./ Enhance descending Inhibitory pain pathway - Duloxetine* 2.5 Calcium channel 2 - Pregabalin 30-60 1 ligands Block 2 subunit of calcium channel 1 75-600 + serotonin syndrome ./ , , chronic neuropathic pain : Duloxetine 31 +/- + +/- + ++ tramadol ./ 2.6 Paracetamol, NSAIDs, COX-2 inhibitors * -- -- 2549 11 11
    • 3.2 neuropathic pain Burning TCA SNRI Sodium channel blockers Calcium channel 2 1 ligands Opioids 3.3 Amitriptyline Venlafaxine Duloxetine Carbamazepine Oxcarbazepine Gabapentin Pregabalin Tramadol Morphine Lancinating ++ + ++ +/+/++ ++ + +/- +/+/+/++ ++ +/+/+/+/- neuropathic pain Hyperalgesia Allodynia ++ + ++ + + ++ ++ + +/- ++ + + + + ++ ++ + +/- Paresthesia, dysesthesia + +/+/+ + + + + +/- neuropathic pain neuropathic pain DPN PHN TGN Phantom Central pain limb pain TCA Amitriptyline ++ ++ +/+ ++ SNRI Venlafaxine + + +/Duloxetine ++ + +/Sodium channel Carbamazepine +/+/++ + + blockers Oxcarbazepine +/+/++ + + Calcium channel Gabapentin ++ ++ +/+ + Pregabalin ++ ++ +/+ + 2 1 ligands Opioids Tramadol + + +/+/Morphine +/+/+/+/DPN: diabetic peripheral neuropathy, PHN: post herpetic neuralgia, TGN: trigeminal neuralgia 12
    • 3.2 3.4 Trigeminal neuralgia neuropathic pain 1. Microvascular decompression (MVD) 2. 3. 1. ++ 68-95% 70 – 95% 72 – 73% vascular loop compression 5-6 0.1% 1% Gamma knife +/- 2. 47 – 88 % (75 – 92.9 % 24 – 74 % 18 90% ) 10% SRS 1 1 ) 3 ( 48 – persistent paresthesia ( 15.8% 16.3% Radiofrequency thermoregulation + 83 – 97% 49 – 70% 5-7 Motor cortex stimulation +/- Dorsal root entry zone (DREZ) dressing +/- Spinal cord stimulation Motor cortex stimulation +/+/- 10% 42% , , 35% , 13% 36% Post herpetic neuralgia 1. 2. DREZ spinal cord stimulation (60-70% for DREZ) 13
    • 3.4 Phantom limb pain neuropathic pain 1. 2. ( ) Dorsal root entry zone (DREZ) lesion +/For general -Stump pain Deep brain stimulation (DBS) traumatic amputations associated with root avulsion phantom stump pain stump pain +/DBS PVG/PAG grey matter (79%) PVG/PAG plus sensory thalamus/internal capsule (87%) sensory thalamus (58% long-term success) (p < 0.05) DBS nociceptive pain deafferentation pain (63% vs 47% long-term success; p < 0.01) 3. neuroma + +/- Thalamic pain 1. Deep brain stimulation +/- Trial stimulation 50% post-stroke pain 2. 58% Motor cortex stimulation +/- 10% , 42% , 35% , 13% 36% Causalgia, Sympathetic mediated pain 1. 2. 14 Sympathectomy + sympathetic block 66-96% 94% sympathectomy
    • 3.3 Neuropathic pain neuropathic pain 1. 2. 2 1 neuropathic pain RCT (adjunctive therapy) 15 15
    • 2,3 3.3.1 5 (acupuncture) neuropathic pain alternative medicine 40 36 3.5 3.5 / Patient education TENS (Transcutaneous Electrical Nerve Stimulation) - Hi-TENS (conventional) Hi frequency, low intensity - Lo-TENS (acupuncturelike) Lo frequency, Hi intensity ++ Chronic neuropathic pain pacemaker cardiac - 4,5,6,7 9 200 - ( + ) - +/- allodynia -Hi-TENS TENS , Lo-TENS 8 - / - 30 Hi-TENS Lo-TENS trial & error accommodation effects of nerve nerve fiber 16 16 -Hi-TENS cardiac pacemaker
    • 3.5 ( ) / Relaxation techniques Neuropathic pain: Postherpetic neuralgia peripheral neuropathy - - + - General Exercise improve general condition 7,8,17 6,7 ++ (immobilization syndrome) Specific exercise Heat & Cold hot pack, warm bath, ice +/Neuropathic pain - burn sensory impaired - 7 +/-- Desensitization Neuropathic pain - allodynia - 9 sensory deficit DM +/-allodynia ( ) 17
    • 3.3.2 Alternative Medicine: CAM) peripheral neuropathy (mega-vitamins 35) (magnet 10 ( 22) chiropractor ( 21) (Complementary & 43 CAM 30) ( 30) 27 3.6 CAM neuropathic pain 18 18
    • 3.6 / (Acupuncture) Painful diabetic neuropathy, central neuropathic pain in spinal cord injury (SCI) -RCT (postherpetic neuralgia) placebo, sham, painful diabetic neuropathy, central neuropathic pain in SCI - - hepatitis B HIV, Painful peripheral neuropathy 10,14 1-3 (10 4-5 / ( - 6,10 neuropathic pain (balanced 1 ) B6 neuropathy ) Mild degree neuropathic pain +/Central NeP (SCI) painful diabetic neuropathy post-herpetic neuralgia ) neuropathic pain diet) - +/radiculopathy trigeminal neuralgia 1,6,12,13 - ( 5,8,11 peripheral sensitization - + Balanced diet ++ Avoid alcohol +/MTV, B complex, 3B -B6 100 ./ ) -Vitamin E > 400 U/day Parkinson’ disease Alzheimer’s disease +/- 19 19
    • 4 4.1 Diabetic neuropathy 1 2 2 1 13.12 32.33 5 20-33% 10 4 7-13 4 3 1. Distal symmetric diabetic polyneuropathy (DSDP) / 2. Autonomic neuropathy (autonomic neuropathy) DSDP 20 20 2
    • QT 3. Focal and multifocal neuropathy median, radial, ulnar peroneal nerve truncal radiculoneuropathy, (entrapment) , (hyperglycemia) species) polyol pathway (reactive oxygen (advanced glycation endproducts AGEs) protein kinase C 6 2 glucose tolerance test serum electrophoresis, TSH, BUN, Creatinine (skin biopsy) 7 Quantitative sensory testing (QST) 21 21
    • : reductase inhibitors 8,9 aldose nerve growth factor : (focal or multifocal neuropathy) (carbamazepine, gabapentin, pregabalin), antidepressant 10 (amitryptyline, nortryptyline, duloxetine) opioid tramadol strong opioid 11 topical capsaicin 12 0.075% neuropathic pain fludrocortisone midodrine 13 4.2 (Post herpetic neuralgia, PHN) varicella-zoster 1,000 2.2-3.4 1 20 (dermatome) (post herpetic neuralgia) 2 72 acyclovir, valacyclovir 22 22 famciclovir 1-3 PHN
    • PHN1,2 PHN3 amitryptyline 2 PHN 4 PHN gabapentin TCAs tramadol 4.3 pregabalin 1,5 (Trigeminal neuralgia or Tic douloureux) 5.9 3.4 5 100,000 5 (trigger point) trigeminal ganglion (sensory function) 3 (V2,V3) 1 (V1) 2 1 loop demyelination MRI brain multiple sclerosis 600-1,200 arterial 5 venous meningioma 100 . . carbamazepine 2-3 23 23
    • oxcarbazepine baclofen, phenytoin, gabapentin, lamotrigine 1-3 (2) ganglion alcohol micro vascular loop decompression (MVD) Gamma 4 knife radiosurgery 5 MVD 4.4 (Phantom limb pain) 1, 2 phantom sensation acute just post amputation pain chronic residual limb pain phantom phenomena 60-80 (phantom pain) 5-10 (stump pain) 24 (nerve block) 24
    • (randomized control trial) (neuropathic pain) (non invasive treatment) sodium channels (antidepressants) calcium channels opioids randomized controlled trials tricyclic meta analysis 4.5 Central neuropathic pain 8 40 spinothalamic pathway neuronal excitability central neuropathic pain trial randomized controlled 1. Central neuropathic pain, post stroke : TCA pregabalin 2. Spinal cord injury pain: calcium channel 2 1 ligands 3. Pain associated with multiple sclerosis: cannabinoids (level B) 4. Central neuropathic pain : pregabalin, TCAs, lamotrigine, gabapentin (level B) 25 25
    • first second line peripheral neuropathic pain 4.6 (mixed pain) neuropathic pain neuropathic pain neuropathic pain neuropathic pain Cancer pain: neuropathic pain opioids SNRIs gabapentin, pregabalin, TCAs, antiepileptics Painful polyneuropathy o HIV neuropathy antiretrovirals CYP450 CYP450 gabapentin o Drug-induced neuropathy o Guillain–Barre syndrome gabapentin carbamazepine opioids Nerve injury pain radicular pain (include back pain), post-traumatic/postsurgical neuropathic pain complex regional pain syndromes (CRPS) paracetamol neuropathic pain NSAIDs neuropathic pain neuropathic pain 26 26
    • 5 neuropathic pain 1. 2. / neuropathic pain 3 3. 4. 5. (chronic pain) first-line drugs (chronic pain syndrome) 5.1 7/10 50 2 strong opioids invasive techniques / 1 / 5.2 5.3 5.4 5.5 5.6 5.7 27 27
    • 1 (Quality of Evidence) 1 1.1 (systematic (randomize-controlled clinical trials) 1.2 randomize-controlled, clinical trial) review) 1 (a well-designed, 2 2.1 (non-randomized, controlled, clinical trials) 2.2 (well-designed, non-randomized, controlled clinical trial) 2.3 (cohort) (case control analytic studies) / (multiple time series) 2.4 . . 2480 3 4 3.1 3.2 (descriptive studies) (fair-designed, controlled clinical trial) 4.1 (consensus) 4.2 2 (anecdotal report) 28 28
    • 2 “ (strength of recommendation)” (prolonged life) (improved quality of life) (decreased morbidity) ( / ) “ 1 “++” ” “++” 1 ( “+/-”) 50 Papanicolaou 2 “++” CT / MRI brain “++” ( “+/-”) 1. “+/-” :- 2. 3. 4. 29 29
    • 5. 12 (systematic review and consensus of peer reviewers) / “5 ” (1) (2) / (3) ( ) “5 ” (1) (2) (3) (4) (5) 1. (safety) (efficacy) (effectiveness) (benefit of population and entire society) (efficiency) (safety) monitoring program: SMP) harm) 2. ( (safety NNH: number needed to (efficacy) / 30 30
    • ( needed to treat) 3. NNT: number (effectiveness) / / / 3.1 3.2 3.3 3.4 4. (benefit of population and entire society) (utility) 5. / (efficiency) 4 31 31
    • 3 :“++”, 1. / 1.1. “--” / ( 2 1 : :- - ) (randomize-controlled, clinical trial) 1 1.2. 2 : (non-randomized, controlled, clinical trial) 2 1.2.1. 1.2.2. 1.2.3. (cohort) (case-control) (multiple-time series) “+”, 2. “-” / 1 / ( ( 2.1. adrenaline ) ) / / :1( 1 2.2. 1 3 / , 2 2 ) 4 “+/-” 3. ( ) 3.1. ( ) 3.1.1. 3.1.2. 3.1.3. 3.1.4. 3.1.5. 3.2. 3.3. 3.4. 3.5. :- (surrogated end-point) (safety monitoring program : SMP) . ( 1 / 2) . (ultimate end points) 32 32
    • 4 Neuropathic pain 2 1. (stimulus-independent spontaneous pain) (burning) (intermittent shooting), (lancinating sensations), (electric shock-like pain) (tingling) “paresthesias” “dysesthesias” 2. (stimulus-dependent stimulus-evoked pain) “Hyperalgesia” (mechanical) (thermal) (chemical) “Allodynia” Mechanical allodynia ( 1A) Thermal allodynia 40 ( neuropathic pain 2) ( 1. 2. 3. 4. 1B) (pinprick sense) (tuning fork) 128-Hz 33 33
    • 1 A B 2 34 neuropathic pain
    • 35 Assess distinct qualities of NeP 10 NeP = neuropathic pain Intended use Patient administered Type Number of Questions Question / pain descriptor NPS2 Patient administered Discriminate between NeP and Non-NeP 12 NPQ3 Patient administered Screen NeP 3 NPQ Short Form4 neuropathic pain Patient administered Identify NeP 7 NPSI5 Patient administered Screen NP 6 ID PAIN6 Patient administered Screen NP 7 DN4 for patients7 Patient administered Screen NP component in LBP 9 Pain DETECT8 Patient administered Identify NeP 7 LANSS for patietns9 Physician administered Discriminate NeP from Non-NeP 10 DN4 for physicians7 Physician administered Identify NeP 7 LANSS for physician9 5 35
    • 6 Thai DN4 1. ? 1. 2. 3. 2. ? 4. 5. 6. 7. 3. 8. 9. 4. 10. =1 =0 4 _______/10 neuropathic pain Chaudakshetrin P, Prateepavanich P, Chira-Adisai W, Tassanawipas W, Leechavengvongs S, Kitisomprayoonkul W. Crosscultural adaption to the Thai language of the neuropathic pain diagnostic questionnaire (DN4). J Med Assoc Thai 2007; 90:1860-5. 36 36
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    • ·π«∑“߇«™ªØ‘∫—µ¿“«–ª«¥‡Àµÿ欓∏‘ ¿“æª√– “∑ ‘ (Clinical Practice Guideline for Neuropathic Pain) æ.». 2551 ®—¥∑”‚¥¬  ¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡∑»‰∑¬  π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“µ‘