Carbamazepine for acute and chronic pain
ABSTRACT Anticonvulsant drugs have been used in the management of pain since the 1960s. The clinical impression is that they are useful for chronic neuropathic pain, especially when the pain is lancinating or burning.
To evaluate the analgesic effectiveness and adverse effects of the anticonvulsant medicine carbamazepine for pain management in clinical practice and to identify a clinical research agenda. Migraine and headache studies are not included in this review.
Randomised trials (RCTs) of anticonvulsants in acute, chronic or cancer pain were identified by MEDLINE (1966-2004), EMBASE (1994-2004), SIGLE (1980-2004) and the Cochrane Controlled Trials Register (CENTRAL/CCTR) (Cochrane Library Issue 3, 2003). In addition, 41 medical journals were hand searched for a previous version of this review. Additional reports were identified from the reference list of the retrieved papers, and by contacting investigators. Date of most recent search: November 2004.
Randomised trials reporting the analgesic effects of carbamazepine in patients, with subjective pain assessment as either the primary or a secondary outcome.
Data were extracted by two independent reviewers, and trials were quality scored. Numbers-needed-to-treat (NNTs) were calculated from dichotomous data for effectiveness, adverse effects and drug-related study withdrawal, for individual studies and for pooled data.
Twelve studies were included (404 participants). Four studies included trigeminal neuralgia patients. Two studies which provided evaluable data yielded an NNT for effectiveness of 1.8 (95%CI 1.4-2.8). For diabetic neuropathy there was insufficient data for an NNT to be calculated.Numbers-needed-to-harm (NNHs) were calculated where possible by combining studies for each drug entity irrespective of the condition treated. The results were, for minor harm, carbamazepine 3.7 (CI 2.4-7.8), NNHs for major harm were not statistically significant for carbamazepine compared with placebo. There is no evidence that carbamazepine is effective for acute pain.
There is evidence to show that carbamazepine is effective but trials are small.
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ABSTRACT: There are over 10.000 conditions known to generate pain, and oncology is one of the fields correlated with suffering. Both the acute and the chronic pain that emerge in cancers require a complex and prompt approach. In addition to the standard medication used in the palliative medicine, an increasing number of trials focus on evaluating other drugs, including psychiatric ones, in order to alleviate this invalidating symptom. Antidepressants and antiepileptic drugs proved efficient in controlling the acute pain, but further evaluation is needed. More extended studies were carried out concerning alternative therapies for the chronic cancer pain, including antidepressants, antiepileptics, neuroleptics and NMDA receptor antagonists. These substances can be used both as comedication or main therapy in case of opioid intolerrance. Moreover, they can also allievate the psychiatric symptoms so frequently encountered in the oncologic population.
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ABSTRACT: Anticonvulsants (of which gabapentin is one) are a group of medicines commonly used for treating 'fits' or epilepsy, but which are also effective for treating pain. The type of pain which responds well is neuropathic pain, e.g., postherpetic neuralgia (persistent pain experienced in an area previously affected by shingles) and painful complications of diabetes. Approximately two-thirds of patients who take either carbamazepine or gabapentin can expect to achieve good pain relief. There is no evidence of benefit in acute pain.Cochrane database of systematic reviews (Online) 02/2005; 20(3):CD005452. DOI:10.1002/14651858.CD005452 · 5.94 Impact Factor
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ABSTRACT: Off-Label Product Discussion: All medications discussed will be off-label, except the following medications with the US Food and Drug Administration indication listed alphabetically: carbamazepine—trigeminal neuralgia; duloxetine—dia-betic peripheral neuropathy; gabapentin—postherpetic neuralgia; opioids—pain; pregabalin—diabetic peripheral neu-ropathy and postherpetic neuralgia; and transdermal 5% lidocaine—postherpetic neuralgia. PURPOSE: To review the use of pharmacotherapy for the treatment of neuropathic pain, with a special emphasis on anticonvulsant medications. EPIDEMIOLOGY: By conservative estimates, between 0.6% and 1.5% of the US population suffers from conditions leading to neuropathic pain. Most commonly, nearly 6 million indi-viduals seek treatment for pain related to diabetic peripheral neuropathy (DPN) and posther-petic neuralgia (PHN), although the list of underlying etiologies for this type of pain includes a myriad of conditions ranging from infectious diseases to musculoskeletal causes. REVIEW SUMMARY: The pathophysiology of neuropathic pain and select mechanisms of action and pharmacologic targets for analgesia are discussed. At present, a complete understanding of the precise pathophysiology for this type of pain and the mechanisms of actions for many of these therapeutic agents is lacking; however, several research-based theories are presented. US Food and Drug Administration (FDA)-approved, first-line and second-line medication reg-imens, including several classes of medications, are reviewed, focusing on anticonvulsant med-ications and new related agents, such as pregabalin. Specifically, recommendations issued by the Fourth International Conference on the Mechanisms and Treatment of Neuropathic Pain are discussed. Recommendations are based on the results of multiple, randomized clinical trials, published studies, and the clinical experience of the conference faculty. The 2 types of neuro-pathic pain emphasized in this article are PHN and DPN. Our understanding of pain mecha-nisms relate primarily to animal nerve injury models rather than these 2 conditions. The fact that PHN and DPN are primarily used for pharmacologic studies is related to: lack of other bet-ter uniform clinical models, and confounding psychosocial factors often seen in other less-defined clinical problems as complex regional pain syndrome or low-back pain. TYPE OF AVAILABLE EVIDENCE: In all examples of recommendations below, randomized, place-bo-controlled trials are used. Much of the information comes from the Annals of Neurology 2003, which is the result of an international expert panel using all available evidence for their conclusions on neuropathic pain. All trial data are cited whenever recommendations are made. GRADE OF AVAILABLE EVIDENCE: Fair CONCLUSION: A variety of pharmacologic agents from classes including anticonvulsants, antidepressants, and opioids, among others, are available for the management of neuro-pathic pain—a condition for which our understanding is still in its infancy despite the fact that it afflicts millions of individuals who suffer from diabetes and other chronic illnesses. Decisions regarding which medication to use for management of neuropathic pain may come down to a number of practical considerations. These may include which drugs have US FDA approval; evidence of efficacy and safety from randomized, controlled trials; cost or formulary limita-tions; and personal experience. In the end, rational polypharmacy—using combinations of multiple medications with different mechanisms of action—may be the most effective means of gaining relief for particularly challenging patients. In the future, research may focus on developing a more complete understanding of neuropathic pain, with the goal of targeting therapies to modulate pain at its source within the nervous system.