Lidocaine, Botulinum Toxin Type A, and Carbamazepine Could Become Primary Treatment for Trigeminal Neuralgia
In this study, the authors reviewed 13 clinical trials including 672 patients in a network meta-analysis to evaluate the efficacy and performance of 8 drugs with respect to trigeminal neuralgia (TN). The only outcome measured was response rate, expressed as the odds ratio with 95% credible/confidence intervals.
All 8 drugs investigated alleviated TN more than placebo except for pimozide and proparacaine.
Only lidocaine (LDC), botulinum toxin type A (BTX-A), and carbamazepine (CBZ) had a statistically better performance than placebo when considering the primary endpoint response rate, indicating that they are the most effective drugs for treating patients with TN. Also, LDC, BTX-A, and CBZ were shown to be highly efficacious and could be recommended as the primary choice of treatment for TN. (See Yang F, Lin Q, Dong L, et al. Efficacy of 8 different drug treatments for patients with trigeminal neuralgia: a network meta-analysis. Clin J Pain. 2018;34(7):685-690. doi: 10.1097/AJP.0000000000000577.)
Recent Guidelines for Hypertension Management
In a systematic electronic literature review covering the years 1966 to 2015 and conducted by Doctor Evidence, LLC, the authors considered 3 questions:
1. Is self-conducted blood pressure measurement superior to office-based monitoring?
2. What is the optimal target for blood pressure control to prevent adverse outcomes?
3. What should be the first-line therapy for hypertension?
In answering the questions, the authors concluded that:
* A modest but significant improvement in systolic blood pressure in controlled trials of self-administered blood pressure measurement is seen at 6 months, but not at 12 months, although the method may be a useful adjuvant to office care.
* Lowering systolic blood pressure to less than 130 mm Hg may reduce the risk of significant complications such as stroke, heart failure, and other cardiovascular events.
* No class of medications was significantly better than thiazides and thiazide-like diuretics as a first-line therapy for any outcome.
(See Reboussin DM, Allen NB, Griswold ME, et al. Systematic Review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19):2176-2198. doi: 10.1016/j.jacc.2017.11.004.)
Three Case Reports: Paravertebral Catheters, Occipital Neuralgia, and Postherpetic Neuralgia
Here are 3 recently published case reports that describe effective clinical care in pain management:
Case 1-Perioperative anesthesia and pain management with paravertebral catheter. A 76-year-old woman with end-stage renal disease was admitted with right upper extremity edema due to thoracic outlet syndrome. After placement of blocks at T1 and T2, a paravertebral catheter was inserted. General anesthesia was induced and the first rib resected. Safe and effective postoperative analgesia was produced by infusions through the catheter. (See Kalava A, Pribish AM. T1 paravertebral catheter for postoperative pain management after first rib resection for venous thoracic outlet syndrome: a case report. A A Pract. 2018;11(1):1-3. doi:10.1213/XAA.0000000000000698.)
Case 2-Near-complete pain resolution in occipital neuralgia using clinical-grade transcutaneous electrical nerve stimulation (TENS) unit. Severe occipital neuralgia in a 39-year-old woman was refractory to all standard therapies. The patient was given 3 sessions of 20 minutes each using conventional TENS therapy set to operate at a frequency of 60 to 80 Hz at an amplitude up to her level of tolerance. Electrodes were placed on each side of the midline in the occipital area of the scalp at the nuchal line near the inion. Near-complete pain resolution was reported after the fourth session. Maintenance therapy consisted of TENS unit use at home, as needed, physical therapy, deep tissue massage, and tizanidine 6 mg orally once a day. She was still pain-free after 12 months. The authors note that the TENS unit was not the product generally available online but a more powerful one used in clinical studies. (See Ghaly RF, Plesca A, Candido KD. Transcutaneous electrical nerve stimulation in treatment of occipital neuralgia: a case report. A A Pract. 2018;11(1):4-7. doi:10.1213/XAA.0000000000000709.)
Case 3-Correcting zinc deficiency-alleviated postherpetic neuralgia. Based on the finding that some patients with postherpetic neuralgia (PHN) have zinc deficiency, 2 male patients, ages 68 and 76 years, were treated effectively with IV zinc infusions. Zinc can alleviate pain through binding to Ca (v) 3.2 T channels and N-methyl-D-aspartate (NMDA) receptors. Gabapentinoids are first-line drugs for PHN and may be effective through inhibition of NMDA receptors and calcium channels. Therefore, zinc, orally or parenterally, may be appropriate supplemental therapy in some cases. (See Lin Y-T, Lan KM, Wang LK, et al. Treatment of postherpetic neuralgia with intravenous administration of zinc sulfate: a case report. A A Pract. 2018;11(1): 8-10. doi: 10.1213/XAA.0000000000000712.)