Oliveira Rogério Adas Ayres de, Baptista Abrahão Fontes, Sá Katia Nunes, Barbosa Luciana Mendonça, Nascimento Osvaldo José Moreira do, Listik Clarice, Moisset Xavier, Teixeira Manoel Jacobsen, Andrade Daniel Ciampi de
Universidade de São Paulo, Faculdade de Medicina, Centro de Dor, Departamento de Neurologia, São Paulo SP, Brazil.
Academia Brasileira de Neurologia, Departamento Científico de Dor, São Paulo SP, Brazil.
Arq Neuropsiquiatr. 2020 Dec 14;78(11):741-752. doi: 10.1590/0004-282X20200166. eCollection 2020.
Central neuropathic pain (CNP) is often refractory to available therapeutic strategies and there are few evidence-based treatment options. Many patients with neuropathic pain are not diagnosed or treated properly. Thus, consensus-based recommendations, adapted to the available drugs in the country, are necessary to guide clinical decisions.
To develop recommendations for the treatment of CNP in Brazil.
Systematic review, meta-analysis, and specialists opinions considering efficacy, adverse events profile, cost, and drug availability in public health.
Forty-four studies on CNP treatment were found, 20 were included in the qualitative analysis, and 15 in the quantitative analysis. Medications were classified as first-, second-, and third-line treatment based on systematic review, meta-analysis, and expert opinion. As first-line treatment, gabapentin, duloxetine, and tricyclic antidepressants were included. As second-line, venlafaxine, pregabalin for CND secondary to spinal cord injury, lamotrigine for CNP after stroke, and, in association with first-line drugs, weak opioids, in particular tramadol. For refractory patients, strong opioids (methadone and oxycodone), cannabidiol/delta-9-tetrahydrocannabinol, were classified as third-line of treatment, in combination with first or second-line drugs and, for central nervous system (CNS) in multiple sclerosis, dronabinol.
Studies that address the treatment of CNS are scarce and heterogeneous, and a significant part of the recommendations is based on experts opinions. The CNP approach must be individualized, taking into account the availability of medication, the profile of adverse effects, including addiction risk, and patients' comorbidities.
中枢性神经病理性疼痛（CNP）通常对现有的治疗策略难以奏效，且基于证据的治疗选择很少。许多神经病理性疼痛患者未得到正确诊断和治疗。因此，有必要制定基于共识的建议，以适应该国可用的药物，从而指导临床决策。
制定巴西CNP治疗的建议。
进行系统评价、荟萃分析，并参考专家意见，综合考虑疗效、不良事件情况、成本以及公共卫生领域的药物可及性。
共找到44项关于CNP治疗的研究，20项纳入定性分析，15项纳入定量分析。根据系统评价、荟萃分析和专家意见，将药物分为一线、二线和三线治疗药物。一线治疗药物包括加巴喷丁、度洛西汀和三环类抗抑郁药。二线药物包括文拉法辛、用于脊髓损伤继发CND的普瑞巴林、用于中风后CNP的拉莫三嗪，以及与一线药物联合使用的弱阿片类药物，特别是曲马多。对于难治性患者，强阿片类药物（美沙酮和羟考酮）、大麻二酚/Δ⁹-四氢大麻酚被列为三线治疗药物，可与一线或二线药物联合使用，对于多发性硬化症患者的中枢神经系统（CNS），可使用屈大麻酚。
针对CNS治疗的研究稀缺且具有异质性，很大一部分建议基于专家意见。CNP的治疗方法必须个体化，要考虑药物的可及性、不良反应情况，包括成瘾风险，以及患者的合并症。
