Ischemic Monomelic Neuropathy Medication
- Author: Michael T Andary, MD, MS; Chief Editor: Robert H Meier, III, MD more...
No medications are specific for ischemic monomelic neuropathy (IMN). Medications used to treat neuropathic pain may be helpful. Such pain may, in fact, be quite debilitating in IMN, although it is uncertain how frequently it presents. Medications for neuropathic pain include anticonvulsants (gabapentin, pregabalin), antidepressants (duloxetine, amitriptyline, paroxetine, sertraline, venlafaxine), local anesthetics, and opioids (propoxyphene, methadone).
Use of certain antiepileptic drugs, such as the gamma-aminobutyric acid (GABA) analogue gabapentin (Neurontin), has proven helpful in some cases of neuropathic pain. These drugs have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanisms of analgesia could include improved sleep, altered perception of pain, and increase in the pain threshold.
Gabapentin has anticonvulsant properties and antineuralgic effects; however, its exact mechanism of action is unknown. This drug is structurally related to GABA but does not interact with GABA receptors. Titration to effect can take place over several days (300mg on day 1, 300mg twice on day 2, and 300mg 3 times on day 3).
Pregabalin is a structural derivative of GABA. Its mechanism of action is unknown. Pregabalin binds with high affinity to the alpha2-delta site (a calcium channel subunit). In vitro, it reduces the calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. Pregabalin has been approved by the US Food and Drug Administration (FDA) for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as an adjunctive therapy in partial-onset seizures.
These make up a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission, and they block the active reuptake of norepinephrine and serotonin.
Duloxetine is indicated for diabetic peripheral neuropathic pain. It is a potent inhibitor of neuronal serotonin and norepinephrine reuptake.
Amitriptyline is an analgesic for certain chronic and neuropathic pain.
Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake. Paroxetine may decrease neuropathic pain and help with sleep and mood disorders (depression or depressive symptoms).
Sertraline selectively inhibits presynaptic serotonin reuptake. It may decrease neuropathic pain and help with sleep and other mood disorders (depression or depressive symptoms).
Venlafaxine inhibits neuronal serotonin and norepinephrine reuptake. In addition, it causes beta-receptor down-regulation. The drug may decrease neuropathic pain and help with sleep and mood disorders (depression or depressive symptoms).
These agents may decrease neuropathic pain; they should be used to decrease pain, increase function, and improve quality of life. The adverse effects, which include, but are not limited to, cognitive difficulties, tolerance, addiction, and nausea, need to be taken very seriously. The use of contracts to assure the appropriate use of opiates and that link the use of opiate medication to good behavior are helpful.
If a patient's behavior deteriorates, consider decreasing or discontinuing the opiate medication, because it may be contributing to the problem. The use of opiates only at night to improve sleep may be the most effective use of these medications for the long-term treatment of neuropathic pain.
Methadone is a long-acting opioid used in the management of severe pain. It inhibits ascending pain pathways, diminishing the perception of and response to pain.
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