- Email: [email protected]
Topiramate Relieves Idiopathic and Symptomatic Trigeminal Neuralgia
Vol. 21 No. 5 May 2001
mal gastrointestinal motility. Use of pancreatic enzymes may relieve symptoms and levomepromazine may be an effective antiemetic in such terminally ill patients. Zbigniew Zylicz, MD, PhD Hospice Rozenheuvel Rozendaal, The Netherlands Małgorzata Krajnik, MD, PhD Department of Palliative Medicine The Ludwig Rydygier University of Medical Sciences Bydgoszcz, Poland PII S0885-3924(01)00276-7
Acknowledgments We thank Dr. R.G. Twycross from Michael Sobell House in Oxford, UK for his kind comments.
References 1. Lichtenstein DR, Carr-Locke DL. Endoscopic palliation for unresectable pancreatic carcinoma. Surg Clin North Am 1995;75:969–988. 2. Bruno MJ, Haverkort EB, Tijssen GP, et al. Placebocontrolled trial of enteric-coated pancreatin microsphere treatment in patients with unresectable cancer of the pancreatic head region. Gut 1998;42:92–96. 3. Barkin JS, Goldberg RI, Sfakianakis GN, Levi J. Pancreatic carcinoma is associated with delayed gastric emptying. Dig Dis Sci 1986;31:265–267. 4. Sommers DK, Snyman JR, van Wyk M. Effect of metoclopramide, ondansetron and granisetron on aldosterone secretion in man. Eur J Clin Pharmacol 1993;44:337–339. 5. Steadman CJ, Talley NJ, Phillips SF, Zinsmeister AR. Selective 5-hydroxytryptamine type 3 receptor antagonism with ondansetron as treatment for diarrhea-predominant irritable bowel syndrome: a pilot study. Mayo Clin Proc 1992;67:732–738. 6. Twycross RG, Back I. Nausea and vomiting in advanced cancer. Eur J Palliative Care 1998;5:39–45. 7. Skinner J, Skinner A. Levomepromazine for nausea and vomiting in advanced cancer. Hosp Med 1999;60:568–570.
Topiramate Relieves Idiopathic and Symptomatic Trigeminal Neuralgia To the Editor: Topiramate (TPM) is a new antiepileptic drug (AED) recently approved for the treat-
Letters
367
ment of partial seizures. It has a broad spectrum of anticonvulsant actions that may result from actions on voltage-gated Na channels and Ca channels, as well as on GABA and glutamate channels.1 Recently, TPM was found to be effective for several neuralgic symptoms, including intercostal neuralgia,2 cluster headache,3 and infantile spasms.4 Trigeminal neuralgia (TN) is a sudden recurrent pain in the distribution of the fifth cranial nerve. It may be essential or secondary to demonstrable structural lesions, such as aneurysm or multiple sclerosis (MS). In MS patients, TN is likely due to an ephaptic transmission between demyelinated axons at the fifth root entry zone in the pons. Carbamazepine (CBZ) is the first choice medication for TN. Many patients are resistant to this drug, however, or cannot tolerate it. This is most likely when other neurological symptoms are present, such as in MS. Recently, other AEDs, such as lamotrigine (LMT) and gabapentin (GBP),5 have been shown to be effective for treating TN, both in essential and in secondary cases. We report 4 subjects, 1 with essential TN and 3 with secondary TN, who were resistant or intolerant of other AEDs, but could be successfully treated with TPM. In each case, subjective pain level was rated utilizing a previously described three-point scale: 0 ⫽ no pain, 1 ⫽ mild, 2 ⫽ moderate, 3 ⫽ severe.5 Titration began with 25 mg/daily and was increased by 25 mg every three days until pain relief was achieved or dosage reached 300 mg daily. The trial was conducted at the Department of Neurological Sciences and Vision, University of Genoa and S. Camillo Hospital, Rome and written informed consent was obtained from all subjects.
Case 1 A 57-year-old woman had essential TN for more than 15 years. Brain MRI was normal. She was previously treated with CBZ (1600 mg/ day), phenytoin (PHT) (300 mg/day), lamotrigine (300 mg/day) and GBP (2400 mg/day), with which she experienced only transient pain relief. The patient was successfully treated with TPM at a dose of 300 mg daily, and was painfree after six months of treatment.
Case 2 A 35-year-old man underwent a surgical intervention for arteriovenous malformation in
368
Letters
Vol. 21 No. 5 May 2001
Table 1 Clinical Characteristics and Drug Regimen Patient 1 2 3 4
Disease
Age
Gender
Disease duration (yr)
TN duration
TPM dosage
T0
T1
T2
Essential AVM MS MS
57 35 58 39
F M F F
15 3 32 9
18 y 2y 15 y 1y
300 150 200 200
3 2 2 2
1 0 0 0
1 0 0 0
T0 ⫽ Pre-treatment score; T1 ⫽ Post-treatment; T2 ⫽ six months score; AVM ⫽ arteriovenous malformation; MS ⫽ multiple sclerosis.
the posterior fossa, had residual cerebellar and pyramidal signs, and later developed lancinating paroxysmal pain in the trigeminal area. He was intolerant to low dose CBZ and GBP due to worsening cerebellar signs, and he developed a skin rash with LMT. He was successfully treated with 150 mg of TPM.
Case 3 A 58-year-old woman had clinically definite MS and TN, and was previously treated with CBZ, PHE, LMT, and GBP without benefit or adverse effects. The patient was successfully treated with TPM at 200 mg daily.
Case 4 A 39-year-old woman with TN related to clinically definite MS was previously treated with CBZ, but this treatment was interrupted due to skin rash. GBP was ineffective at a dosage of 900 mg and it was not possible to increase the dosage due to worsening neurological symptoms. The patient was successfully treated with TPM at 200 mg daily. Table 1 provides patient characteristics, TPM dosage levels, and pain scores at T0 (pretreatment), T1 (pain relief achieved), and T2 (after six months of treatment). Patients presented with a classic TN with trigger points and pain described as electrical discharges within the fifth nerve distribution. Only Patient 2 experienced sensory impairment in the trigeminal area. During the treatment period, no significant adverse effects were reported by any patient. Patient 3 complained of mild asthenia and dry mouth. The varied mechanisms of action of TPM, which act at different neural transmission levels, such as sodium channels and enhancing GABA concentration, may explain the antinociceptive action of TPM on TN. Other advantages of TPM include the lack of relevant adverse effects and few interactions with other drugs. AEDs such as CBZ, LMT, or GBP are reported
to decrease neuropathic pain, although many patients either do not achieve optimal pain relief or are unable to reach high dosage levels, due to adverse effects. For these patients, TPM can represent a new therapeutic option. Claudio Solaro, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy Michele Messmer Uccelli, BA Department of Social and Health Services and Research The Italian Multiple Sclerosis Society Genoa, Italy Giampaolo Brichetto, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy Claudio Gasperini, MD Department of Neurology S. Camillo Hospital Rome, Italy GianLuigi Mancardi, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy PII S0885-3924(01)00275-5
References 1. Glauser TA. Topiramate. Epilepsia 1999;40:S71– S80. 2. Bajwa ZH, Sami N, Warfield CA, Wootton J. Topiramate relieves refractory intercostal neuralgia. Neurology 1999;52:1917. 3. Wheeler SD, Carrazana EJ. Topiramate-treated cluster headache. Neurology 1999;53:234. 4. Glauser TA, Clark PO, Strawburg R. A pilot study of topiramate in the treatment of infantile spasms. Epilepsia 1998;39:1324–1328. 5. Solaro C, Lunardi GL, Capello E, et al. An open label trial of gabapentin treatment of paroxysmal symptoms in multiple sclerosis patients. Neurology 1998;51:609–611.
mal gastrointestinal motility. Use of pancreatic enzymes may relieve symptoms and levomepromazine may be an effective antiemetic in such terminally ill patients. Zbigniew Zylicz, MD, PhD Hospice Rozenheuvel Rozendaal, The Netherlands Małgorzata Krajnik, MD, PhD Department of Palliative Medicine The Ludwig Rydygier University of Medical Sciences Bydgoszcz, Poland PII S0885-3924(01)00276-7
Acknowledgments We thank Dr. R.G. Twycross from Michael Sobell House in Oxford, UK for his kind comments.
References 1. Lichtenstein DR, Carr-Locke DL. Endoscopic palliation for unresectable pancreatic carcinoma. Surg Clin North Am 1995;75:969–988. 2. Bruno MJ, Haverkort EB, Tijssen GP, et al. Placebocontrolled trial of enteric-coated pancreatin microsphere treatment in patients with unresectable cancer of the pancreatic head region. Gut 1998;42:92–96. 3. Barkin JS, Goldberg RI, Sfakianakis GN, Levi J. Pancreatic carcinoma is associated with delayed gastric emptying. Dig Dis Sci 1986;31:265–267. 4. Sommers DK, Snyman JR, van Wyk M. Effect of metoclopramide, ondansetron and granisetron on aldosterone secretion in man. Eur J Clin Pharmacol 1993;44:337–339. 5. Steadman CJ, Talley NJ, Phillips SF, Zinsmeister AR. Selective 5-hydroxytryptamine type 3 receptor antagonism with ondansetron as treatment for diarrhea-predominant irritable bowel syndrome: a pilot study. Mayo Clin Proc 1992;67:732–738. 6. Twycross RG, Back I. Nausea and vomiting in advanced cancer. Eur J Palliative Care 1998;5:39–45. 7. Skinner J, Skinner A. Levomepromazine for nausea and vomiting in advanced cancer. Hosp Med 1999;60:568–570.
Topiramate Relieves Idiopathic and Symptomatic Trigeminal Neuralgia To the Editor: Topiramate (TPM) is a new antiepileptic drug (AED) recently approved for the treat-
Letters
367
ment of partial seizures. It has a broad spectrum of anticonvulsant actions that may result from actions on voltage-gated Na channels and Ca channels, as well as on GABA and glutamate channels.1 Recently, TPM was found to be effective for several neuralgic symptoms, including intercostal neuralgia,2 cluster headache,3 and infantile spasms.4 Trigeminal neuralgia (TN) is a sudden recurrent pain in the distribution of the fifth cranial nerve. It may be essential or secondary to demonstrable structural lesions, such as aneurysm or multiple sclerosis (MS). In MS patients, TN is likely due to an ephaptic transmission between demyelinated axons at the fifth root entry zone in the pons. Carbamazepine (CBZ) is the first choice medication for TN. Many patients are resistant to this drug, however, or cannot tolerate it. This is most likely when other neurological symptoms are present, such as in MS. Recently, other AEDs, such as lamotrigine (LMT) and gabapentin (GBP),5 have been shown to be effective for treating TN, both in essential and in secondary cases. We report 4 subjects, 1 with essential TN and 3 with secondary TN, who were resistant or intolerant of other AEDs, but could be successfully treated with TPM. In each case, subjective pain level was rated utilizing a previously described three-point scale: 0 ⫽ no pain, 1 ⫽ mild, 2 ⫽ moderate, 3 ⫽ severe.5 Titration began with 25 mg/daily and was increased by 25 mg every three days until pain relief was achieved or dosage reached 300 mg daily. The trial was conducted at the Department of Neurological Sciences and Vision, University of Genoa and S. Camillo Hospital, Rome and written informed consent was obtained from all subjects.
Case 1 A 57-year-old woman had essential TN for more than 15 years. Brain MRI was normal. She was previously treated with CBZ (1600 mg/ day), phenytoin (PHT) (300 mg/day), lamotrigine (300 mg/day) and GBP (2400 mg/day), with which she experienced only transient pain relief. The patient was successfully treated with TPM at a dose of 300 mg daily, and was painfree after six months of treatment.
Case 2 A 35-year-old man underwent a surgical intervention for arteriovenous malformation in
368
Letters
Vol. 21 No. 5 May 2001
Table 1 Clinical Characteristics and Drug Regimen Patient 1 2 3 4
Disease
Age
Gender
Disease duration (yr)
TN duration
TPM dosage
T0
T1
T2
Essential AVM MS MS
57 35 58 39
F M F F
15 3 32 9
18 y 2y 15 y 1y
300 150 200 200
3 2 2 2
1 0 0 0
1 0 0 0
T0 ⫽ Pre-treatment score; T1 ⫽ Post-treatment; T2 ⫽ six months score; AVM ⫽ arteriovenous malformation; MS ⫽ multiple sclerosis.
the posterior fossa, had residual cerebellar and pyramidal signs, and later developed lancinating paroxysmal pain in the trigeminal area. He was intolerant to low dose CBZ and GBP due to worsening cerebellar signs, and he developed a skin rash with LMT. He was successfully treated with 150 mg of TPM.
Case 3 A 58-year-old woman had clinically definite MS and TN, and was previously treated with CBZ, PHE, LMT, and GBP without benefit or adverse effects. The patient was successfully treated with TPM at 200 mg daily.
Case 4 A 39-year-old woman with TN related to clinically definite MS was previously treated with CBZ, but this treatment was interrupted due to skin rash. GBP was ineffective at a dosage of 900 mg and it was not possible to increase the dosage due to worsening neurological symptoms. The patient was successfully treated with TPM at 200 mg daily. Table 1 provides patient characteristics, TPM dosage levels, and pain scores at T0 (pretreatment), T1 (pain relief achieved), and T2 (after six months of treatment). Patients presented with a classic TN with trigger points and pain described as electrical discharges within the fifth nerve distribution. Only Patient 2 experienced sensory impairment in the trigeminal area. During the treatment period, no significant adverse effects were reported by any patient. Patient 3 complained of mild asthenia and dry mouth. The varied mechanisms of action of TPM, which act at different neural transmission levels, such as sodium channels and enhancing GABA concentration, may explain the antinociceptive action of TPM on TN. Other advantages of TPM include the lack of relevant adverse effects and few interactions with other drugs. AEDs such as CBZ, LMT, or GBP are reported
to decrease neuropathic pain, although many patients either do not achieve optimal pain relief or are unable to reach high dosage levels, due to adverse effects. For these patients, TPM can represent a new therapeutic option. Claudio Solaro, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy Michele Messmer Uccelli, BA Department of Social and Health Services and Research The Italian Multiple Sclerosis Society Genoa, Italy Giampaolo Brichetto, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy Claudio Gasperini, MD Department of Neurology S. Camillo Hospital Rome, Italy GianLuigi Mancardi, MD Department of Neurological Sciences and Vision University of Genoa Genoa, Italy PII S0885-3924(01)00275-5
References 1. Glauser TA. Topiramate. Epilepsia 1999;40:S71– S80. 2. Bajwa ZH, Sami N, Warfield CA, Wootton J. Topiramate relieves refractory intercostal neuralgia. Neurology 1999;52:1917. 3. Wheeler SD, Carrazana EJ. Topiramate-treated cluster headache. Neurology 1999;53:234. 4. Glauser TA, Clark PO, Strawburg R. A pilot study of topiramate in the treatment of infantile spasms. Epilepsia 1998;39:1324–1328. 5. Solaro C, Lunardi GL, Capello E, et al. An open label trial of gabapentin treatment of paroxysmal symptoms in multiple sclerosis patients. Neurology 1998;51:609–611.