三叉神经痛卡马西平.docx

1、三叉神经痛卡马西平Classical trigeminal neuralgia (CTN) is a severe neuropathic pain in the distribution of one or more branches of the trigeminal nerve, which occurs in recurrent episodes, causing deterioration in quality of life, affecting everyday habits and inducing severe disability. The aim of this revi

2、ew is to give an overview of the current literature on pharmaceutical treatment options for CTN in the elderly. The first-line treatment for the management of CTN in adults is an antiepilepticcarbamazepine or oxcarbazepine. There is a lack of research on the use of antiepileptics in the elderly. Thi

3、s is a deficiency, as the use of antiepileptics raises a number of problems due to the polypharmacotherapy common in older patients. This can induce drug interactions due to co-morbidities and changes in pharmacokinetics and pharmacodynamics. Furthermore, the side effects of carbamazepine include ce

4、ntral nervous system disturbances, such as a lack of balance, dizziness, somnolence, renal dysfunction and cardiac arrhythmias, which are poorly tolerated by the elderly. Unfortunately, the efficacy and safety of alternative treatment options have not been systematically evaluated. On the basis of t

5、he current literature, it is not possible to give an evidence-based recommendation for first-line pharmaceutical management of CTN specifically for the elderly.Go to:Drugs Aging. 2015; 32(9): 717726.Published online 2015 Sep 4.doi:10.1007/s40266-015-0293-6PMCID:PMC4579266Pharmaceutical Management of

6、 Trigeminal Neuralgia in the ElderlyM. A. E.-M. OomensandT. ForouzanfarAuthor informationCopyright and License informationGo to:AbstractClassical trigeminal neuralgia (CTN) is a severe neuropathic pain in the distribution of one or more branches of the trigeminal nerve, which occurs in recurrent epi

7、sodes, causing deterioration in quality of life, affecting everyday habits and inducing severe disability. The aim of this review is to give an overview of the current literature on pharmaceutical treatment options for CTN in the elderly. The first-line treatment for the management of CTN in adults

8、is an antiepilepticcarbamazepine or oxcarbazepine. There is a lack of research on the use of antiepileptics in the elderly. This is a deficiency, as the use of antiepileptics raises a number of problems due to the polypharmacotherapy common in older patients. This can induce drug interactions due to

9、 co-morbidities and changes in pharmacokinetics and pharmacodynamics. Furthermore, the side effects of carbamazepine include central nervous system disturbances, such as a lack of balance, dizziness, somnolence, renal dysfunction and cardiac arrhythmias, which are poorly tolerated by the elderly. Un

10、fortunately, the efficacy and safety of alternative treatment options have not been systematically evaluated. On the basis of the current literature, it is not possible to give an evidence-based recommendation for first-line pharmaceutical management of CTN specifically for the elderly. Classical tr

11、igeminal neuralgia (CTN) is a severe neuropathic pain in the distribution of one or more branches of the trigeminal nerve, which occurs in recurrent episodes, causing deterioration in quality of life, affecting everyday habits and inducing severe disability. The aim of this review is to give an over

12、view of the current literature on pharmaceutical treatment options for CTN in the elderly. The first-line treatment for the management of CTN in adults is an antiepilepticcarbamazepine or oxcarbazepine. There is a lack of research on the use of antiepileptics in the elderly. This is a deficiency, as

13、 the use of antiepileptics raises a number of problems due to the polypharmacotherapy common in older patients. This can induce drug interactions due to co-morbidities and changes in pharmacokinetics and pharmacodynamics. Furthermore, the side effects of carbamazepine include central nervous system

14、disturbances, such as a lack of balance, dizziness, somnolence, renal dysfunction and cardiac arrhythmias, which are poorly tolerated by the elderly. Unfortunately, the efficacy and safety of alternative treatment options have not been systematically evaluated. On the basis of the current literature

15、, it is not possible to give an evidence-based recommendation for first-line pharmaceutical management of CTN specifically for the elderly.Key PointsGo to:IntroductionIn the primary care sector, diagnosis and initial management of orofacial pain are often performed by family doctors and dentists 1.

16、Trigeminal neuralgia (TN) is a specific diagnosis based on clinical findings, a thorough clinical history and an examination 2. A multidisciplinary team should manage patients with complicated facial pain 1. According to the International classification of headache disorders, third edition (ICHD-3),

17、 TN is defined as a disorder characterized by recurrent, unilateral, brief, electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli 3. The annual overall incidence of TN ranges from 12

18、.6/100,000 to 27/100,000 people per year, with an increase in the incidence with advancing age 4. The mechanism of TN is described as hyperexcitability of trigeminal root fibres near the entry zone into the pons because of mechanical compression (vascular or tumorous) or inflammatory demyelination (

19、multiple sclerosis). Empirical evidence has indicated that vascular compression of the trigeminal nerve root is associated with TN in about 95% of patients 5. Magnetic resonance imaging (MRI) studies have given more insights into the pathogenesis of TN. Trigeminal nerve microstructure abnormalities

20、can be identified with new MRI techniques together with trigeminal tractography. Demyelination without significant axonal injury seems to be an important factor in the pathogenesis of TN. Furthermore, there seems to be a state of maintained sensitization of trigeminal nociceptive systems in the brai

21、n. Antiepileptic drugs are thought to work in the treatment of TN by blocking voltage-sensitive sodium channels, making brain cells less excitable 6. Also, grey-matter volume reduction has been found in the primary and secondary somatosensory cortices of TN patients 4,7.TN can be divided into sympto

22、matic TN (STN) and classical (idiopathic) TN (CTN) 3. STN can be classified by causative or contributing factors, as proposed by Eller etal. 8for example, trigeminal neuropathic pain resulting from multiple sclerosis plaques or tumours. Unfortunately, most TN is idiopathic, and the aetiology is not

23、clear.The guidelines on pharmaceutical TN management published by the American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS) recommend carbamazepine (CBZ; 2001200mg/day) or oxcarbazepine (OXC; 6001800mg/day) as first-line therapy 9. Patients unresponsive to

24、CBZ or OXC should be referred for add-on therapy with lamotrigine or surgery. Elderly patients (defined as persons aged 60 years or older) often present with a number of co-morbid and age-related conditions, which often require polypharmacy. Antiepileptics have well-known interactions with other dru

25、gs. Therefore, it is a challenge to establish a medical treatment for CTN in the elderly without inducing changes in pharmacodynamics and pharmacokinetics, and without causing safety problems.The aim of this review is to give an overview of the currently available literature on the pharmaceutical ma

26、nagement of CTN patients, with a focus on the elderly.Go to:Materials and MethodsInclusion and Exclusion CriteriaThe studies included in this review were all double-blind, randomized, controlled trials (RCTs) involving non-surgical treatment of CTN. The review excluded articles on STN, articles not

27、available in English and non-RCT study designs.Outcome MeasuresPain relief, defined as decreased frequency and decreased intensity of painful paroxysms, was regarded as the primary outcome. Secondary outcome measures were side effects.Literature SearchesTo identify eligible studies, Medline, Embase

28、and Clinicaltrials.gov were searched with the MeSH term trigeminal neuralgia. The search was restricted to RCTs, clinical trials and English-language articles.Data Collection and AnalysisThe titles and abstracts of the articles were screened, and the two authors of the review (MO and TF) decided whi

29、ch articles were eligible for inclusion. Information on the numbers of participants, length of follow-up and outcome measures was extracted from each article, using a data extraction form.Assessment of Risks of BiasThe risks of bias in each trial were assessed by scoring the security of randomizatio

30、n, allocation concealment, comparability of groups at baseline, double blinding and handling of dropouts. In cases of uncertainty, the authors of the relevant article were contacted whenever possible.Go to:ResultsLiterature SearchesThe literature search resulted in 171 relevant studies. After review

31、 of the abstracts, 18 articles involving non-surgical treatment of CTN were identified. Of these, six articles assessed antiepileptic drugs and 12 investigated non-antiepileptic drugs (Fig.1).Fig.1Flowchart of article selection.i.n.intranasal application,m.mucosal application,s.c.subcutaneous applic

32、ationStudy DescriptionsAn overview of all included studies is given in Table1. The four studies investigating the effectiveness of CBZ, all published before 1970, showed that CBZ reduced both the frequency and the intensity of painful paroxysms in 76% of included patients 1013. A total of 165 patients were included mean age 58years (range 3484), and there was a mean follow-up of 23 months (range 146). CBZ dosages ranged from 100 to 2400mg/day. Side effects of drowsiness, constipation, vertigo, nausea and vomiting, and a rash were described.