Zin Che S, Nissen Lisa M, Smith Maree T, O'Callaghan James P, Moore Brendan J
School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia.
CNS Drugs. 2008;22(5):417-42. doi: 10.2165/00023210-200822050-00005.
Neuropathic pain is a persistent pain condition that develops secondary to nerve injury. The two most common types of peripheral neuropathic pain are post-herpetic neuralgia (PHN) and painful diabetic neuropathy (PDN). Amitriptyline, nortriptyline, desipramine and imipramine are TCAs that have been shown to be effective for the symptomatic relief of PHN and PDN. Serotonin noradrenaline reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine have been shown to be very promising for the treatment of PDN with fewer adverse effects than TCAs. Selective serotonin reuptake inhibitors (SSRIs) were shown in a number of studies to have some efficacy in relieving PDN-related pain, yet other studies of the SSRIs have demonstrated conflicting outcomes. Most of the older antiepileptic studies were performed in patients with PDN; consequently, little is known about the efficacy of these drugs in patients with PHN. Carbamazepine, phenytoin and valproic acid were shown to be effective in ameliorating PDN-related pain. Other antiepileptic agents, including lamotrigine, oxcarbazepine and topiramate, have demonstrated some beneficial effects for the treatment of PDN, although they were also found to be ineffective in some PDN studies. alpha2delta Ligands such as gabapentin and pregabalin have been proven to be effective for the treatment of PHN and PDN in a number of large placebo-controlled trials. These drugs are useful not only in relieving pain but also in improving quality of life. Although the use of opioids for the treatment of neuropathic pain is controversial, a number of studies support the efficacy and safety of opioids in the treatment of neuropathic pain. Of these, oxycodone and tramadol have been shown to be superior to placebo for the treatment of PHN and PDN. A number of small studies have shown that dextromethorphan was effective in patients with PDN but not in patients with PHN. Topical agents such as lidocaine 5% patches and topical capsaicin are useful in ameliorating pain in patients with PHN but these agents are unsatisfactory for use as a sole agent. Although a number of drug treatments are available for the symptomatic relief of neuropathic pain symptoms, these agents do not provide satisfactory relief in all patients. For these patients, other treatment alternatives such as combination drug therapy that produces pain relief via distinctly different mechanisms may be successful. The purpose of this review is to compare the efficacy and limitations of currently available pharmacological treatments for the symptomatic relief of PHN and PDN, and to discuss the potential of combination therapy in PHN and PDN.
神经性疼痛是一种继发于神经损伤的持续性疼痛病症。两种最常见的外周神经性疼痛类型是带状疱疹后神经痛（PHN）和糖尿病性疼痛性神经病变（PDN）。阿米替林、去甲替林、地昔帕明和丙咪嗪是三环类抗抑郁药，已被证明对PHN和PDN的症状缓解有效。血清素去甲肾上腺素再摄取抑制剂（SNRIs），如文拉法辛和度洛西汀，已被证明在治疗PDN方面非常有前景，且副作用比三环类抗抑郁药少。一些研究表明，选择性血清素再摄取抑制剂（SSRIs）在缓解与PDN相关的疼痛方面有一定疗效，但其他关于SSRIs的研究结果相互矛盾。大多数较早的抗癫痫药物研究是在PDN患者中进行的；因此，对于这些药物在PHN患者中的疗效知之甚少。卡马西平、苯妥英和丙戊酸已被证明可有效改善与PDN相关的疼痛。其他抗癫痫药物，包括拉莫三嗪、奥卡西平和托吡酯，已显示出对PDN治疗有一些有益效果，尽管在一些PDN研究中也发现它们无效。α2δ配体，如加巴喷丁和普瑞巴林，已在多项大型安慰剂对照试验中被证明对PHN和PDN的治疗有效。这些药物不仅有助于缓解疼痛，还能改善生活质量。尽管使用阿片类药物治疗神经性疼痛存在争议，但一些研究支持阿片类药物在治疗神经性疼痛方面的有效性和安全性。其中，羟考酮和曲马多已被证明在治疗PHN和PDN方面优于安慰剂。一些小型研究表明，右美沙芬对PDN患者有效，但对PHN患者无效。局部用药，如5%利多卡因贴片和局部辣椒素，有助于改善PHN患者的疼痛，但这些药物作为单一药物使用并不令人满意。尽管有多种药物可用于缓解神经性疼痛症状，但这些药物并非对所有患者都能提供令人满意的缓解。对于这些患者，其他治疗选择，如通过截然不同的机制产生疼痛缓解的联合药物治疗可能会取得成功。本综述的目的是比较目前可用的药物治疗对PHN和PDN症状缓解的疗效和局限性，并讨论联合治疗在PHN和PDN中的潜力。
