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Re: Desipramine in neuropathic pain franco neuro

Posted by ed_uk on May 14, 2005, at 9:42:17

In reply to Re: Desipramine in neuropathic pain ed_uk, posted by franco neuro on May 13, 2005, at 22:46:42

Hi Franco,

>Nerve pain and weekness in my left leg and foot and visceral and pelvic pain.

I hope you don't mind me asking. What is the cause of your pain?

>I wish I had taken desipramine instead of amitriptyline.

Why don't you try desipramine now?
I've taken lofepramine, a similar drug to desipramine, it didn't cause any cognitive impairment.

>IV ketamine (NMDA antagonist) and IV lidocaine...........

But these treatments are not easy to 'get hold of'. Why don't you try the more usual treatments first? You could try desipramine next. Being interested in the NMDA receptor, I expect you've already tried dextromethorphan. Perhaps you could consider oral amantadine, IV amantadine has also been used.

'Dextromethorphan is effective in a dose-related fashion in selected patients with diabetic neuropathy. This was not true of postherpetic neuralgia, suggesting a difference in pain mechanisms. Selective approaches to pain-relevant N-methyl-d-aspartate receptors are warranted.'

Diabet Med. 2003 Feb;20(2):114-8.

A pilot study of the beneficial effects of amantadine in the treatment of painful diabetic peripheral neuropathy.

Amin P, Sturrock ND.

Department of Diabetes and Endocrinology, Nottingham City Hospital, Nottingham, UK.

BACKGROUND: Current symptomatic treatments for painful peripheral neuropathy in diabetes have variable efficacy in individual patients. Amongst other chemical transmitters involved in pain reception, the N-methyl-D-aspartate (NMDA) subtype of excitatory amino acid receptor is involved in nociception. Amantadine was recently shown to act as a non-competitive antagonist of NMDA and may be effective in the treatment of neuropathic pain in patients with cancer. We have looked at the benefit of amantadine infusion in diabetic patients with painful peripheral neuropathy. METHODS: Seventeen patients with diabetes (nine men) completed this double-blind randomized crossover placebo-controlled trial of intravenous amantadine. The average age was 58.4 (sd 11) years, with duration of diabetes of 21.1 (8.7) years and duration of painful peripheral neuropathy symptoms of 29.1 (24) months. All analgesics except paracetamol were stopped for 4 weeks prior to the study. Infusions were carried out on a weekly basis with amantadine being administered intravenously as a single 200-mg infusion. The Neuropathy Symptom Score (NSS), together with visual analogue scales, were used to assess current pain intensity (VAS-P) pre-therapy and 1 week later VAS-P was repeated together with a visual analogue scale used to assess relief in pain (VAS-R) and the Physicians Global Evaluation (PGE) score used to assess response to therapy. RESULTS: Pre-therapy, the NSS was 6.8 (6.3-7.4) at baseline, remaining unchanged at 6.6 (5.8-7.4) after placebo (P = 0.33), but fell to 4.6 (3.4-5.8) after amantadine (P = 0.003 vs. baseline and P = 0.02 vs. placebo). The baseline perception of pain was scored as 7.8 cm (7.3-8.3), with no difference following placebo, at 8.2 cm (7.7-8.6) (P = 0.34), but following amantadine it fell to 6.2 cm (4.9-7.8) (P = 0.01 compared with pre-therapy, P = 0.003 compared with placebo). The perception of relief from pain following placebo was only 0.2 (-0.2 to +0.6) but following amantadine was 10-fold better at 1.9 (0.8-3.1) (P = 0.016). The PGE assessment of pain relief was -0.3 (-0.5 to 0) for placebo and following amantadine was 0.8 (0.1-1.5) (P = 0.006). CONCLUSIONS: Our study has shown that intravenous amantadine is beneficial in reducing the pain of painful peripheral neuropathy, with an effect sustained for at least 1 week after an infusion.

Can patients with chronic neuropathic pain be cured by acute administration of the NMDA receptor antagonist amantadine?

Eisenberg E, Pud D.

Pain Relief Unit, Rambam Medical Center, Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa.

The treatment of neuropathic pain remains a challenge as it rarely leads to long-term relief of symptoms. We report three patients with chronic neuropathic pain, in whom acute administration of the N-methyl-D-aspartate (NMDA) receptor antagonist amantadine resulted in complete resolution of symptoms, presumably due to termination the central 'wind-up' phenomenon.

Pain. 1998 Apr;75(2-3):349-54.

The NMDA receptor antagonist amantadine reduces surgical neuropathic pain in cancer patients: a double blind, randomized, placebo controlled trial.

Pud D, Eisenberg E, Spitzer A, Adler R, Fried G, Yarnitsky D.

Pain Relief Unit, Rambam Medical Center, Haifa, Israel.

Neuropathic pain is often severe, persistent, and responds poorly to analgesic medications. Recent evidence suggests that N-methyl-D-aspartate (NMDA) receptor antagonists may be effective in the treatment of neuropathic pain. The present trial was designed to test the efficacy of acute administration of the NMDA receptor antagonist amantadine in relieving surgical neuropathic pain in patients with cancer. The study sample consisted of 15 cancer patients with the diagnosis of surgical neuropathic pain. Two 500 ml infusions of either 200 mg amantadine or placebo were administered over a 3 h period, in a randomized order, 1 week apart from each other. Spontaneous and evoked pain were measured for 48 h before treatment, during treatment, and for 48 h following treatment. An average pain reduction of 85% was recorded at the end of amantadine infusion vs. 45% following placebo administration. The difference in pain relief between the two treatments was statistically significant (P = 0.009). Mean pain intensity remained significantly lower during the 48 h following amantadine treatment as compared with the 48 h prior to treatment (31% reduction; P = 0.006), whereas no such effect was found with the placebo (6% reduction; P = 0.40). Amantadine, but not the placebo, also reduced 'wind up' like pain (caused by repeated pinpricking) in four patients. We conclude that amantadine infusion is a safe and effective acute treatment for surgical neuropathic pain in cancer patients. Further trials with long-term oral or parenteral amantadine treatment should be conducted.




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