miércoles, 3 de enero de 2018

Dolor neuropático / Neurophatic pain

Enero 2, 2018. No. 2951
Una revisión del manejo del dolor del miembro fantasma: desafíos y soluciones.
A review of the management of phantom limb pain: challenges and solutions.
J Pain Res. 2017 Aug 7;10:1861-1870. doi: 10.2147/JPR.S124664. eCollection 2017.
BACKGROUND: Phantom limb pain (PLP) occurs in 50% and 80% of amputees. Although it is often classified as a neuropathic pain, few of the large-scale trials of treatments for neuropathic pain included sufficient numbers of PLP sufferers to have confidence that they are effective in this condition. Many therapies have been administered to amputees with PLP over the years; however, as of yet, there appears to be no first-line treatment. OBJECTIVES: To comprehensively review the literature on treatment modalities for PLP and to identify the challenges currently faced by clinicians dealing with this pain. METHOD: MEDLINE, EMBASE, CINAHL, British Nursing Index, Cochrane and psycINFO databases were searched using "Phantom limb" initially as a MeSH term to identify treatments that had been tried. Then, a secondary search combining phantom limb with each treatment was performed to find papers specific to each therapy. Each paper was assessed for its research strength using the GRADE system. RESULTS: Thirty-eight therapies were identified. Overall, the quality of evidence was low. There was one high-quality study which used repetitive transcutaneous magnetic stimulation and found a statistical reduction in pain at day 15 but no difference at day 30. Significant results from single studies of moderate level quality were available for gabapentin, ketamine and morphine; however, there was a risk of bias in these papers. Mirror therapy and associated techniques were assessed through two systematic reviews, which conclude that there is insufficient evidence to support their use. CONCLUSION: No decisions can be made for the first-line management of PLP, as the level of evidence is too low. Robust studies on homogeneous populations, an understanding of what amputees consider a meaningful reduction in PLP and agreement of whether painintensity is the legitimate therapeutic target are urgently required.
KEYWORDS: pain; phantom limb pain; review; treatment
La ketamina en el tratamiento del dolor crónico según medicina basada en la evidencia
F. Neira Reina y J. L. Ortega García
Rev. Soc. Esp. Dolor vol.23 no.6 Madrid nov./dic. 2016
La ketamina es un antagonista no competitivo de los receptores NMDA y tiene un amplio mecanismo de acción que involucra, además, a los receptores AMPA, kainato, ácido gamma-aminobutírico, opioides, monoaminérgicos, muscarínicos y nicotínicos. Actúa sobre los canales de calcio y sodio voltaje-dependientes, interviene en la síntesis y liberación del óxido nítrico e inhibe la recaptación de serotonina. La interacción con todos estos mecanismos de acción hace que tenga una importante participación sobre mecanismos del dolor, inflamación, neuroprotección y tolerancia de opioides.  En este trabajo se revisan las diferentes vías de administración de la ketamina, su dosificación, las modalidades de administración, la duración del tratamiento, las indicaciones según los niveles de evidencia disponibles y los efectos secundarios; para establecer su eficacia en la terapéutica del dolor crónico y promover un tratamiento más específico, en aquellas patologías en las que se ha demostrado una mayor eficacia. Se realizó una búsqueda en Trip Database Population Intervention Comparison Outcome (PICO), National Guidelines Clearinghouse, Cochrane Library, Medline, CMA infobase, Health Services/Technology Assessment, New Zealand Guidelines Group y Scottish Intercollegiate Guidelines Network. La ketamina tiene una gran versatilidad en cuanto a sus vías de administración (intravenosa, intramuscular, subcutánea, sublingual, oral, rectal, nasal, transdérmica, epidural y subaracnoidea), así como modalidades de administración (bolos, infusión continua). No obstante, la vía oral es la más utilizada y preferida para el tratamiento del dolor crónico. Sin embargo, no disponemos de una formulación oral comercializada, lo que dificulta su utilización. El empleo clínico de la ketamina requiere una cuidadosa selección del paciente y valoración de la relación riesgo/beneficio. Se debe tener presente los antecedentes de abuso de drogas ante el riesgo potencial de abuso del fármaco.  Se dispone de evidencia sobre la eficacia de la ketamina en pacientes con dolor oncológico refractario y en el síndrome doloroso regional complejo (SDRC). Hay evidencia moderada sobre la eficacia de la ketamina intravenosa a dosis bajas, en el SDRC, que no justifica su utilización sistemática en este síndrome. En el dolor neuropático, la ketamina se ha mostrado especialmente eficaz en el control de la alodinia, hiperalgesia e hiperpatía, pero existen controversias sobre su utilización. La ketamina oral puede tener un lugar en el tratamiento del dolor crónico de los pacientes refractarios a tratamientos habituales. Se ha mostrado útil como coadyuvante de otros analgésicos, especialmente en pacientes en tratamiento con opioides, permitiendo disminuir la dosis e incrementando el control analgésico de los pacientes con dolor crónico.
Palabras clave: Ketamina, dolor crónico, dolor neuropático, síndrome doloroso regional complejo.
Manejo del dolor crónico neuropático con metadona combinada con ketamina: un ensayo clínico aleatorizado, doble ciego, con control activo.
Management of Neuropathic Chronic Pain with Methadone Combined with Ketamine: A Randomized, Double Blind, Active-Controlled Clinical Trial.
Pain Physician. 2017 Mar;20(3):207-215.
BACKGROUND: Methadone and ketamine are used in neuropathic pain management. However, the benefits of both drugs association are uncertain in the treatment of neuropathic pain. OBJECTIVE: Our primary objective was test the hypothesis that oral methadone combined with oral ketamine is more effective than oral methadone or ketamine alone in reducing neuropathic pain. STUDY DESIGN: We conducted a randomized, double blind, active-controlled parallel-group clinical trial. METHODS: Forty-two patients with neuropathic pain refractory to conventional therapy were randomly assigned to receive oral methadone (n = 14), ketamine (n = 14), or methadone plus ketamine (n = 14) over a 3-month period. RESULTS: During these 90 days, we observed pain scores using a visual analogical scale (VAS), allodynia, burning/shooting pain, and some side effects. All treatments were effective in reducing pain scores by at least 40%. However, a significant improvement in pain was observed only in the ketamine alone group compared with both the methadone or methadone/ketamine groups. No significant differences were observed among the treatment groups for the reduction of burning or shooting pain, while ketamine alone was more effective than methadone or methadone/ketamine for the reduction of allodynia. LIMITATIONS: Formal assessment for awareness of the allocation was not performed, some co-intervention bias may have occurred, our results could be only relevant to the patient population investigated and the use of VAS as the primary outcome detect changes in pain intensity but not to assess neuropathic pain symptoms. CONCLUSION: This study indicates that ketamine was better than methadone or methadone/ketamine for treating neuropathic pain.Key words: Multimodal analgesia, refractory pain, NMDA receptor, opioid.

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