Serrano Ancor, Gálvez Rafael, Paremés Elena, Navarro Ana, Ochoa Dolores, Pérez Concepción
Pain Clinic, Department of Anesthesia and Reanimation, Hospital Universitari de Bellvitge, L'Hospital et de Llobregat, Spain.
Pain Clinic, Hospital Universitario Virgen de las Nieves, Granada, Spain.
Pain Pract. 2023 Feb;23(2):167-179. doi: 10.1111/papr.13176. Epub 2022 Nov 12.
The use of off-label pharmacotherapies for neuropathic pain (NP) is growing relating to the many unmet needs of patients. However, clinical guidelines fail to address it, and the available evidence is sparse and fragmented. We arranged a formal expert consensus to address this controversial issue and provide some guidance on judicious use.
A two-round standard Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 40-item questionnaire prepared by the authors. Consensus on each statement was defined as at least either 80% endorsement or rejection after the second round.
Forty-three and thirty-seven panelists participated in the first and second round, respectively. Consensus was reached in 34 out of 40 statements. Endorsed alternatives for unresponsive patients include non-gabapentinoid antiepileptics (oxcarbazepine and eslicarbazepine), venlafaxine, intravenous lidocaine (when doses can be optimized), and some vaporized cannabinoids (under appropriate surveillance). In addition, lacosamide, low-dose naltrexone, propofol, or ketamine could prove beneficial if subjected to more research. Other options were rejected, and there was controversy about the usefulness of topical preparations.
For patients who do not respond to standard NP treatments, some other viable pharmacological options can be attempted before advancing to other therapeutic stages. This may help patients who are reluctant to or have some contraindication for interventional therapies.
由于患者存在诸多未满足的需求，用于治疗神经性疼痛（NP）的非标签药物疗法的使用正在增加。然而，临床指南未涉及这一问题，现有证据也稀少且零散。我们组织了一次正式的专家共识会议来解决这一有争议的问题，并就合理使用提供一些指导。
针对作者编制的一份40项的临时问卷，对有NP研究和管理经验的疼痛科专家进行了两轮标准的德尔菲调查。第二轮后，对每条陈述的共识定义为至少80%的认可或否定。
第一轮和第二轮分别有43名和37名小组成员参与。40条陈述中有34条达成了共识。对于无反应的患者，认可的替代药物包括非加巴喷丁类抗癫痫药（奥卡西平和艾司利卡西平）、文拉法辛、静脉注射利多卡因（当剂量可优化时）以及一些汽化大麻素（在适当监测下）。此外，如果进行更多研究，拉科酰胺、低剂量纳曲酮、丙泊酚或氯胺酮可能被证明是有益的。其他选项被否定，局部制剂的有效性存在争议。
对于对标准NP治疗无反应的患者，在进入其他治疗阶段之前，可以尝试一些其他可行的药物选择。这可能有助于那些不愿接受或有介入治疗禁忌症的患者。
