三叉神经痛卡马西平.docx

三叉神经痛卡马西平.docx

《三叉神经痛卡马西平.docx》由会员分享，可在线阅读，更多相关《三叉神经痛卡马西平.docx（9页珍藏版）》请在冰豆网上搜索。

三叉神经痛卡马西平

Classicaltrigeminalneuralgia（CTN）isasevereneuropathicpaininthedistributionofoneormorebranchesofthetrigeminalnerve,whichoccursinrecurrentepisodes,causingdeteriorationinqualityoflife,affectingeverydayhabitsandinducingseveredisability.TheaimofthisreviewistogiveanoverviewofthecurrentliteratureonpharmaceuticaltreatmentoptionsforCTNintheelderly.Thefirst-linetreatmentforthemanagementofCTNinadultsisanantiepileptic—carbamazepineoroxcarbazepine.Thereisalackofresearchontheuseofantiepilepticsintheelderly.Thisisadeficiency,astheuseofantiepilepticsraisesanumberofproblemsduetothepolypharmacotherapycommoninolderpatients.Thiscaninducedruginteractionsduetoco-morbiditiesandchangesinpharmacokineticsandpharmacodynamics.Furthermore,thesideeffectsofcarbamazepineincludecentralnervoussystemdisturbances,suchasalackofbalance,dizziness,somnolence,renaldysfunctionandcardiacarrhythmias,whicharepoorlytoleratedbytheelderly.Unfortunately,theefficacyandsafetyofalternativetreatmentoptionshavenotbeensystematicallyevaluated.Onthebasisofthecurrentliterature,itisnotpossibletogiveanevidence-basedrecommendationforfirst-linepharmaceuticalmanagementofCTNspecificallyfortheelderly.

Goto:

DrugsAging.2015;32（9）:

717–726.

Publishedonline2015Sep4. doi:

  10.1007/s40266-015-0293-6

PMCID:

 PMC4579266

PharmaceuticalManagementofTrigeminalNeuralgiaintheElderly

M.A.E.-M.Oomens

 and T.Forouzanfar

Authorinformation ► CopyrightandLicenseinformation ►

Goto:

Abstract

Classicaltrigeminalneuralgia（CTN）isasevereneuropathicpaininthedistributionofoneormorebranchesofthetrigeminalnerve,whichoccursinrecurrentepisodes,causingdeteriorationinqualityoflife,affectingeverydayhabitsandinducingseveredisability.TheaimofthisreviewistogiveanoverviewofthecurrentliteratureonpharmaceuticaltreatmentoptionsforCTNintheelderly.Thefirst-linetreatmentforthemanagementofCTNinadultsisanantiepileptic—carbamazepineoroxcarbazepine.Thereisalackofresearchontheuseofantiepilepticsintheelderly.Thisisadeficiency,astheuseofantiepilepticsraisesanumberofproblemsduetothepolypharmacotherapycommoninolderpatients.Thiscaninducedruginteractionsduetoco-morbiditiesandchangesinpharmacokineticsandpharmacodynamics.Furthermore,thesideeffectsofcarbamazepineincludecentralnervoussystemdisturbances,suchasalackofbalance,dizziness,somnolence,renaldysfunctionandcardiacarrhythmias,whicharepoorlytoleratedbytheelderly.Unfortunately,theefficacyandsafetyofalternativetreatmentoptionshavenotbeensystematicallyevaluated.Onthebasisofthecurrentliterature,itisnotpossibletogiveanevidence-basedrecommendationforfirst-linepharmaceuticalmanagementofCTNspecificallyfortheelderly.

Classicaltrigeminalneuralgia（CTN）isasevereneuropathicpaininthedistributionofoneormorebranchesofthetrigeminalnerve,whichoccursinrecurrentepisodes,causingdeteriorationinqualityoflife,affectingeverydayhabitsandinducingseveredisability.TheaimofthisreviewistogiveanoverviewofthecurrentliteratureonpharmaceuticaltreatmentoptionsforCTNintheelderly.Thefirst-linetreatmentforthemanagementofCTNinadultsisanantiepileptic—carbamazepineoroxcarbazepine.Thereisalackofresearchontheuseofantiepilepticsintheelderly.Thisisadeficiency,astheuseofantiepilepticsraisesanumberofproblemsduetothepolypharmacotherapycommoninolderpatients.Thiscaninducedruginteractionsduetoco-morbiditiesandchangesinpharmacokineticsandpharmacodynamics.Furthermore,thesideeffectsofcarbamazepineincludecentralnervoussystemdisturbances,suchasalackofbalance,dizziness,somnolence,renaldysfunctionandcardiacarrhythmias,whicharepoorlytoleratedbytheelderly.Unfortunately,theefficacyandsafetyofalternativetreatmentoptionshavenotbeensystematicallyevaluated.Onthebasisofthecurrentliterature,itisnotpossibletogiveanevidence-basedrecommendationforfirst-linepharmaceuticalmanagementofCTNspecificallyfortheelderly.

KeyPoints

Goto:

Introduction

Intheprimarycaresector,diagnosisandinitialmanagementoforofacialpainareoftenperformedbyfamilydoctorsanddentists[1].Trigeminalneuralgia（TN）isaspecificdiagnosisbasedonclinicalfindings,athoroughclinicalhistoryandanexamination[2].Amultidisciplinaryteamshouldmanagepatientswithcomplicatedfacialpain[1].AccordingtotheInternationalclassificationofheadachedisorders,thirdedition（ICHD-3）,TNisdefinedasadisordercharacterizedbyrecurrent,unilateral,brief,electricshock-likepains,abruptinonsetandtermination,limitedtothedistributionofoneormoredivisionsofthetrigeminalnerveandtriggeredbyinnocuousstimuli[3].TheannualoverallincidenceofTNrangesfrom12.6/100,000to27/100,000peopleperyear,withanincreaseintheincidencewithadvancingage[4].ThemechanismofTNisdescribedashyperexcitabilityoftrigeminalrootfibresneartheentryzoneintotheponsbecauseofmechanicalcompression（vascularortumorous）orinflammatorydemyelination（multiplesclerosis）.EmpiricalevidencehasindicatedthatvascularcompressionofthetrigeminalnerverootisassociatedwithTNinabout95 %ofpatients[5].Magneticresonanceimaging（MRI）studieshavegivenmoreinsightsintothepathogenesisofTN.TrigeminalnervemicrostructureabnormalitiescanbeidentifiedwithnewMRItechniquestogetherwithtrigeminaltractography.DemyelinationwithoutsignificantaxonalinjuryseemstobeanimportantfactorinthepathogenesisofTN.Furthermore,thereseemstobeastateofmaintainedsensitizationoftrigeminalnociceptivesystemsinthebrain.AntiepilepticdrugsarethoughttoworkinthetreatmentofTNbyblockingvoltage-sensitivesodiumchannels,makingbraincellslessexcitable[6].Also,grey-mattervolumereductionhasbeenfoundintheprimaryandsecondarysomatosensorycorticesofTNpatients[4, 7].

TNcanbedividedintosymptomaticTN（STN）andclassical（idiopathic）TN（CTN）[3].STNcanbeclassifiedbycausativeorcontributingfactors,asproposedbyElleret al.[8]—forexample,trigeminalneuropathicpainresultingfrommultiplesclerosisplaquesortumours.Unfortunately,mostTNisidiopathic,andtheaetiologyisnotclear.

TheguidelinesonpharmaceuticalTNmanagementpublishedbytheAmericanAcademyofNeurology（AAN）andtheEuropeanFederationofNeurologicalSocieties（EFNS）recommendcarbamazepine（CBZ;200–1200 mg/day）oroxcarbazepine（OXC;600–1800 mg/day）asfirst-linetherapy[9].PatientsunresponsivetoCBZorOXCshouldbereferredforadd-ontherapywithlamotrigineorsurgery.Elderlypatients（definedaspersonsaged60yearsorolder）oftenpresentwithanumberofco-morbidandage-relatedconditions,whichoftenrequirepolypharmacy.Antiepilepticshavewell-knowninteractionswithotherdrugs.Therefore,itisachallengetoestablishamedicaltreatmentforCTNintheelderlywithoutinducingchangesinpharmacodynamicsandpharmacokinetics,andwithoutcausingsafetyproblems.

TheaimofthisreviewistogiveanoverviewofthecurrentlyavailableliteratureonthepharmaceuticalmanagementofCTNpatients,withafocusontheelderly.

Goto:

MaterialsandMethods

InclusionandExclusionCriteria

Thestudiesincludedinthisreviewwerealldouble-blind,randomized,controlledtrials（RCTs）involvingnon-surgicaltreatmentofCTN.ThereviewexcludedarticlesonSTN,articlesnotavailableinEnglishandnon-RCTstudydesigns.

OutcomeMeasures

Painrelief,definedasdecreasedfrequencyanddecreasedintensityofpainfulparoxysms,wasregardedastheprimaryoutcome.Secondaryoutcomemeasuresweresideeffects.

LiteratureSearches

Toidentifyeligiblestudies,Medline,EmbaseandClinicaltrials.govweresearchedwiththeMeSHterm‘trigeminalneuralgia’.ThesearchwasrestrictedtoRCTs,clinicaltrialsandEnglish-languagearticles.

DataCollectionandAnalysis

Thetitlesandabstractsofthearticleswerescreened,andthetwoauthorsofthereview（MOandTF）decidedwhicharticleswereeligibleforinclusion.Informationonthenumbersofparticipants,lengthoffollow-upandoutcomemeasureswasextractedfromeacharticle,usingadataextractionform.

AssessmentofRisksofBias

Therisksofbiasineachtrialwereassessedbyscoringthesecurityofrandomization,allocationconcealment,comparabilityofgroupsatbaseline,doubleblindingandhandlingofdropouts.Incasesofuncertainty,theauthorsoftherelevantarticlewerecontactedwheneverpossible.

Goto:

Results

LiteratureSearches

Theliteraturesearchresultedin171relevantstudies.Afterreviewoftheabstracts,18articlesinvolvingnon-surgicaltreatmentofCTNwereidentified.Ofthese,sixarticlesassessedantiepilepticdrugsand12investigatednon-antiepilepticdrugs（Fig. 1）.

Fig. 1

Flowchartofarticleselection. i.n. intranasalapplication, m. mucosalapplication, s.c. subcutaneousapplication

StudyDescriptions

AnoverviewofallincludedstudiesisgiveninTable 1.ThefourstudiesinvestigatingtheeffectivenessofCBZ,allpublishedbefore1970,showedthatCBZreducedboththefrequencyandtheintensityofpainfulparoxysmsin76 %ofincludedpatients[10–13].Atotalof165patientswereincluded[meanage58 years（range34–84）],andtherewasameanfollow-upof23months（range1–46）.CBZdosagesrangedfrom100to2400 mg/day.Sideeffectsofdrowsiness,constipation,vertigo,nauseaandvomiting,andarashweredescribed.