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284 RANDOMISED DOUBLE-BLIND CLINICAL TRIAL COMPARING EFFICACY AND SAFETY OF DULOXETINE VS. AMITRIPTYLINE IN PAINFUL DIABETIC NEUROPATHY
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Posters / European Journal of Pain Supplements 4 (2010) 47–146
were treated during 30 minutes, 3 to 5 times a week. Patients were allowed to set the current level themselves. Intensities of spontaneous pain (as measured by the Visual Analogue Scale), and intensities of evoked neuropathic pain (as measured by the Leeds Assessment of Neuropathic Signs and Symptoms scale) were scored on a weekly basis. Results: The results of this pilot study indicate that repeated application of micro-current electrotherapy leads to a significant reduction in both spontaneous pain (−40%), as well as evoked neuropathic pain. The reduction in pain appeared after 1 to 2 weeks, and analgesia was maintained throughout the observation period (of 12 weeks). Conclusions: Micro-current electrotherapy seems to be a promising therapy for the treatment of peripheral neuropathic pain. Further investigations, in order to identify the optimal patient populations and clarify the mode of action of MET, are however mandatory. 283 MUSCULAR COMPRESSION OF FACIAL AND CERVICAL NERVES PRODUCING HEADACHES T. Elbaz, S. Serebnitsky, R. Hertz. Anesthesia, St. Luke’s/Roosevelt Hospital Center, a Hospital of Columbia University College of Physicians and Surgeons, New York, NY, USA Introduction: It was noted that several patients in our clinic suffered from daily headaches that seemed to originate from muscular compression of cervical and facial nerves. We therefore decided to try repeat muscular injections to free the nerves from the daily compression in hopes that this would relieve the headaches. Objectives: To determine if injections of facial and neck muscles on a repeated basis would relieve headache that plagued several patients on a daily basis for years. Methods: Patients who suffered chronic daily headaches that appeared to follow a nerve distribution and who had been refractory to other forms of treatment including but not limited medication, biofeedback, botox, relaxation techniques, etc., were evaluated to see if they might be suffering from nerve compression of facial and neck nerves. If after they were examined it was determined that this might be the case the patients were selected to receive nerve blocks and intramuscular injections on a ever lengthening interval starting at daily and proceding after several months to an as needed sequence. Results: Five out of six patients who were not able to function normally, suffered from daily headaches and had not been headache free for as long 15 years developed headache free intervals of up to 6 weeks after ever lengthening intervals of mucular and nerve block injections. Conclusions: Chronic daily headache is caused by nerve compression of facial and cervical nerves. This produces muscular and neuropathic headache. In our preliminary study we found that these patients may respond to local anesthetics. 284 RANDOMISED DOUBLE-BLIND CLINICAL TRIAL COMPARING EFFICACY AND SAFETY OF DULOXETINE VS. AMITRIPTYLINE IN PAINFUL DIABETIC NEUROPATHY D. Hota1 , H. Kaur1 , D. Bansal1 , A. Chakrabarti1 , P. Dutta2 , A. Bhansali2 . 1 Pharmacology, 2 Endocrinology, PGIMER, Chandigarh, India Objectives: The present study compared the of efficacy and safety of duloxetine and amitriptyline in the control of pain of diabetic neuropathy Methods: A randomized, double-blind, crossover, active control clinical trial with variable dose titration was conducted in 38 patients. Amitriptyline 10, 25, and 50 mg orally once daily and duloxetine 20, 40, 60 mg once daily orally were used. Each dose was given for 2 weeks and dose escalation was made if improvement to previous dose was not satisfactory. A placebo washout of 2 weeks
was given between the two drugs. Assessment for pain relief, overall improvement and adverse events were made at base line, 2, 4 and 6 weeks of drug therapy. Results: Pain relief was found to be good in 18 (49%), moderate in 10 (27%) and mild in 8 (22%) in the duloxetine group and good in 13 (35%), moderate in 9 (24%) and mild in 11 (22%) with amitriptyline by patient’s and physician’s global assessment of overall efficacy and safety. McGill pain questionnaire and Likert pain scale did not show any significant difference between the two agents. Overall 33 events were reported at the end of 6 weeks, 26 (79%) were with amitriptyline (sedation and anticholinergic side effects were being the commonest) and 11 (33%) were with duloxetine (constipation, decreased appetite and dizziness were commonest). The preferred effective dose of duloxetine was 40 mg at bed time. Conclusions: Duloxetine 30 mg once daily may be a suitable alternative to amitiptyline in painful diabetic neuropathy. 285 AUDIT ON PHARMACOLOGICAL TREATMENT OF PAINFUL DIABETIC NEUROPATHIES IN PRIMARY CARE IN NEWPORT, GWENT, UK T. Ivanova-Stoilova, A. Ghei, S. Kadambande. Pain Management Clinic, Anaesthetics Department, Aneurin Bevan Health Board, Newport, UK Introduction: Peripheral neuropathies are disabling complications of diabetes mellitus affecting 25–50% of patients with 15–20 years duration of diabetes. 10% of patients have pain and will need long term symptom control. In May 2008 NICE published guidelines for their management in primary care. Tricyclic antidepressants are recommended as first line agent, gabapentine, pregabalin or duloxetine (whichever is cheaper) as second line, opioids as third line and referral to pain specialist if all fails. Objectives: of our audit was to define prescribing practices in primary care in comparison to national guidelines. Methods: A postal questionnaire was sent to all GPs in Newport, Gwent in May 2009. Hospital notes of patients referred to specialised clinic (May 2008-May 2009) were reviewed for time from onset of symptoms to referral to secondary care. Results: 26/82 (32%) GPs and 14/22 (64%) Primary care centres responded. 29/40 (72%) hospital notes were reviewed. 14/25 (68%) GPs did not use guidelines. Amitriptyline was prescribed as first line agent (76%); Gabapentin as second line (68%) and Pregabalin as third line agent (24%). 24/25 (96%) GPs would like locally adapted guidelines to help with choice of second line agent. Patients with intractable pain were referred to secondary care after 3–10 years of onset. Conclusions: We identified non-compliance with national guidelines with limited use of duloxetine, opiods and delayed referral to specialist services. Locally adapted guidelines and inclusion of duloxetine in local drug formulary is likely to improve symptom control. We plan to re-audit in 12 months. Reference(s) [1] NICE Guidelines: CG66 of May 2008.
286 THE POLYNEUROPATHY ONSET IN PATIENTS WITH PRIMARY PULMONARY TUBERCULOSIS A. Ivashynka, S. Likhachev. Nurology, National Neurology and Neurosurgery Research Center, Minsk, Belarus Introduction: Pulmonary tuberculosis is a life-threatening infectious disease that always goes with a number of complications, more often neurological. Nearly fifty percent of all our patients with primary pulmonary tuberculosis observed for half a year had neurological complications. Among them 80 cases (24%) developed various forms of polyneuropathy. This substantially worsened
Posters / European Journal of Pain Supplements 4 (2010) 47–146
were treated during 30 minutes, 3 to 5 times a week. Patients were allowed to set the current level themselves. Intensities of spontaneous pain (as measured by the Visual Analogue Scale), and intensities of evoked neuropathic pain (as measured by the Leeds Assessment of Neuropathic Signs and Symptoms scale) were scored on a weekly basis. Results: The results of this pilot study indicate that repeated application of micro-current electrotherapy leads to a significant reduction in both spontaneous pain (−40%), as well as evoked neuropathic pain. The reduction in pain appeared after 1 to 2 weeks, and analgesia was maintained throughout the observation period (of 12 weeks). Conclusions: Micro-current electrotherapy seems to be a promising therapy for the treatment of peripheral neuropathic pain. Further investigations, in order to identify the optimal patient populations and clarify the mode of action of MET, are however mandatory. 283 MUSCULAR COMPRESSION OF FACIAL AND CERVICAL NERVES PRODUCING HEADACHES T. Elbaz, S. Serebnitsky, R. Hertz. Anesthesia, St. Luke’s/Roosevelt Hospital Center, a Hospital of Columbia University College of Physicians and Surgeons, New York, NY, USA Introduction: It was noted that several patients in our clinic suffered from daily headaches that seemed to originate from muscular compression of cervical and facial nerves. We therefore decided to try repeat muscular injections to free the nerves from the daily compression in hopes that this would relieve the headaches. Objectives: To determine if injections of facial and neck muscles on a repeated basis would relieve headache that plagued several patients on a daily basis for years. Methods: Patients who suffered chronic daily headaches that appeared to follow a nerve distribution and who had been refractory to other forms of treatment including but not limited medication, biofeedback, botox, relaxation techniques, etc., were evaluated to see if they might be suffering from nerve compression of facial and neck nerves. If after they were examined it was determined that this might be the case the patients were selected to receive nerve blocks and intramuscular injections on a ever lengthening interval starting at daily and proceding after several months to an as needed sequence. Results: Five out of six patients who were not able to function normally, suffered from daily headaches and had not been headache free for as long 15 years developed headache free intervals of up to 6 weeks after ever lengthening intervals of mucular and nerve block injections. Conclusions: Chronic daily headache is caused by nerve compression of facial and cervical nerves. This produces muscular and neuropathic headache. In our preliminary study we found that these patients may respond to local anesthetics. 284 RANDOMISED DOUBLE-BLIND CLINICAL TRIAL COMPARING EFFICACY AND SAFETY OF DULOXETINE VS. AMITRIPTYLINE IN PAINFUL DIABETIC NEUROPATHY D. Hota1 , H. Kaur1 , D. Bansal1 , A. Chakrabarti1 , P. Dutta2 , A. Bhansali2 . 1 Pharmacology, 2 Endocrinology, PGIMER, Chandigarh, India Objectives: The present study compared the of efficacy and safety of duloxetine and amitriptyline in the control of pain of diabetic neuropathy Methods: A randomized, double-blind, crossover, active control clinical trial with variable dose titration was conducted in 38 patients. Amitriptyline 10, 25, and 50 mg orally once daily and duloxetine 20, 40, 60 mg once daily orally were used. Each dose was given for 2 weeks and dose escalation was made if improvement to previous dose was not satisfactory. A placebo washout of 2 weeks
was given between the two drugs. Assessment for pain relief, overall improvement and adverse events were made at base line, 2, 4 and 6 weeks of drug therapy. Results: Pain relief was found to be good in 18 (49%), moderate in 10 (27%) and mild in 8 (22%) in the duloxetine group and good in 13 (35%), moderate in 9 (24%) and mild in 11 (22%) with amitriptyline by patient’s and physician’s global assessment of overall efficacy and safety. McGill pain questionnaire and Likert pain scale did not show any significant difference between the two agents. Overall 33 events were reported at the end of 6 weeks, 26 (79%) were with amitriptyline (sedation and anticholinergic side effects were being the commonest) and 11 (33%) were with duloxetine (constipation, decreased appetite and dizziness were commonest). The preferred effective dose of duloxetine was 40 mg at bed time. Conclusions: Duloxetine 30 mg once daily may be a suitable alternative to amitiptyline in painful diabetic neuropathy. 285 AUDIT ON PHARMACOLOGICAL TREATMENT OF PAINFUL DIABETIC NEUROPATHIES IN PRIMARY CARE IN NEWPORT, GWENT, UK T. Ivanova-Stoilova, A. Ghei, S. Kadambande. Pain Management Clinic, Anaesthetics Department, Aneurin Bevan Health Board, Newport, UK Introduction: Peripheral neuropathies are disabling complications of diabetes mellitus affecting 25–50% of patients with 15–20 years duration of diabetes. 10% of patients have pain and will need long term symptom control. In May 2008 NICE published guidelines for their management in primary care. Tricyclic antidepressants are recommended as first line agent, gabapentine, pregabalin or duloxetine (whichever is cheaper) as second line, opioids as third line and referral to pain specialist if all fails. Objectives: of our audit was to define prescribing practices in primary care in comparison to national guidelines. Methods: A postal questionnaire was sent to all GPs in Newport, Gwent in May 2009. Hospital notes of patients referred to specialised clinic (May 2008-May 2009) were reviewed for time from onset of symptoms to referral to secondary care. Results: 26/82 (32%) GPs and 14/22 (64%) Primary care centres responded. 29/40 (72%) hospital notes were reviewed. 14/25 (68%) GPs did not use guidelines. Amitriptyline was prescribed as first line agent (76%); Gabapentin as second line (68%) and Pregabalin as third line agent (24%). 24/25 (96%) GPs would like locally adapted guidelines to help with choice of second line agent. Patients with intractable pain were referred to secondary care after 3–10 years of onset. Conclusions: We identified non-compliance with national guidelines with limited use of duloxetine, opiods and delayed referral to specialist services. Locally adapted guidelines and inclusion of duloxetine in local drug formulary is likely to improve symptom control. We plan to re-audit in 12 months. Reference(s) [1] NICE Guidelines: CG66 of May 2008.
286 THE POLYNEUROPATHY ONSET IN PATIENTS WITH PRIMARY PULMONARY TUBERCULOSIS A. Ivashynka, S. Likhachev. Nurology, National Neurology and Neurosurgery Research Center, Minsk, Belarus Introduction: Pulmonary tuberculosis is a life-threatening infectious disease that always goes with a number of complications, more often neurological. Nearly fifty percent of all our patients with primary pulmonary tuberculosis observed for half a year had neurological complications. Among them 80 cases (24%) developed various forms of polyneuropathy. This substantially worsened