Clinical Neuroscience

[Drug therapy of neuropathic pain in mirror of latest reccommandations]

KISS Gábor

MARCH 25, 2015

Clinical Neuroscience - 2015;68(03-04)

[Neuropathic pain is considered as a special type of different pain conditions. It’s pathophysiological basis and treatment is completely different from the nociceptive pain. The first comprehensive therapeutic guidelines published approximately a decade ago recommended tricyclic antidepressants, anticonvulsants and opioids. The recent summary presents and evaluates national and international guidelines issued in the last five years. The most frequently suggested drugs by all guidelines are amitriptyline, duloxetine, gabapentin and pregabalin. Pregabalin is the only drug that is recommended first line in all guidelines referred. Opioids are in the second or third line. There seems to be no major development in the pharmacological treatment of the neuropathic pain compared to the earlier recommendations. High quality studies of head to head comparisons and effectiveness of combination therapy are still lacking.]



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Clinical Neuroscience

[Help! Accumulation of manuscripts!]

TAJTI János, RAJNA Péter

Clinical Neuroscience

[Teriflunomide: new oral immunmodulant drug in therapy of multiple sclerosis]

BENCSIK Krisztina, RÓZSA Csilla, VÉCSEI László

[Multiple sclerosis (MS) is the autoimmune, demyelinating, neurodegenerative disorder of the central nervous system (CNS). There are nine drugs available in Hungary reimbursed by the National Health Insurance Fund of Hungary (OEP) to reduce the activity of the disease, from which seven can be used as first line therapies. We have approximately 20 years of experience with the interferon b-1a/1b and glatiramer-acetate products. Though in case of approximately 30% of the patients using one of the first line drugs, the disease remains active, that we call break-through disease. The reasons for break-through disease could be the insufficient adherence and compliance, the appearance of neutralizing antibodies or the high activity of the disease. One of the oral immunomodulating drugs for MS, teriflunomide, was registered in Europe in 2013. Because of the anti-proliferative and anti-inflammatory effect of teriflunomide, it can be used for the reduction of the disease activity in the relapsing-remitting course of MS. The effect of teriflunomide was proved in one Phase II. and four Phase III. (TEMSO, TOWER, TENERE, TOPIC) studies. Teriflunomide 14 mg once daily was able to demonstrate in two consecutive placebo-controlled phase 3 clinical trials that significantly reduces the relapse rate (31.5% and 36.3%) and in both studies significantly reduces the sustained disability progression (29.8% and 31.5%) moreover delays the appearance of the clinically definitive MS in patients with clinically isolated syndrome (CIS). According to the TENERE study there were no significant differences observed between teriflunomide 14 mg and IFNb-1a s.c. in time to failure and annualized relapse rate but the treatment satisfaction domains of global satisfaction, side-effects and convenience were significantly improved with teriflunomide compared with s.c. IFNb-1a. ]

Clinical Neuroscience

[Proconvulsive effect of antiepileptic drugs]


[Antiepileptic drugs can provoke and worsen seizures, what is called paradoxical effect. Paradoxical seizure worsening can occur as a nonspecific manifestation of drug intoxication in number of antiepileptic drugs. The other type is a specific type, when antiepileptic drugs with pure GABAergic and sodium channel blocker mechanism of action provoke myoclonic, absence and atonic seizures in specific epilepsy syndromes, mainly in idiopathic generalized epilepsies. Antiepileptic drug-induced exacerbation of seizures is a common, often unrecognized clinical problem, which can be avoided by a careful syndromic diagnosis and by using broad spectrum antiepileptic drugs.]

Clinical Neuroscience

[Do previous offences predict violent acts in psychiatric patients? A retrospective study in Hungary]

BARAN Brigitta, SZABÓ Ádám Ferenc, KARA Borbála, KOVÁCS Magdolna, UZONYI Adél, ANTAL Albert, UNGVARI S Gabor, GAZDAG Gábor

[Aim - To investigate the presence of offences in the previous past history of perpetrators of violent acts who have undergone forced medical treatment. Methods - The documentation of all patients released over a 10-year period from the National Institute of Forensic Psychiatry (IMEI) was reviewed. A comparison was drawn between patients who were convicted of any type of offense before the violent act (patients with previous offences-PPO) and those who were not (patients with no previous offences-PNO). Results - Eighty-six (29%) and 208 (71%) patients formed the PPO and PNO groups, respectively. Prior contact with psychiatric services was significantly higher in the PPO group (p=0.038) and this group was also more likely to offend under the influence of a psychoactive substance (p<0.001). Exceptional brutality and other qualifying factors were more frequent in the PNO group (p=0.019). Conclusion - As IMEI is the only forensic institution in Hungary, the picture presented here reflects the situation in the entire country. A recidivism rate of 29% is within the internationally published range. ]

Clinical Neuroscience

[Effects of maternal epilepsy and antiepileptic therapy in women during pregnancy]

VANYA Melinda, ÁRVA-NAGY Nóra, SZILI Károly, SZOK Délia, BÁRTFAI György

[Objective - The aim of this study was to analyse the effects of epilepsy and antiepileptic drug (AED) treatment on pregnancy and the perinatal outcome, retrospectively. Methods - We examined the obstetric and fetal outcomes among women with epilepsy (WWE), who were followed-up at the Department of Neurology, and who delivered at the Department of Obstetrics and Gynaecology (n=91) between 31th December 2000 and 31th March 2014. Statistical comparisons of different obstetric and fetal parameters on a sample of 91 WWE and 182 non-WWE were assessed by the chi-square-test, the independent sample t-test. Results - The rate of major congenital malformations (MCMS) among the newborns of all AEDs exposed mothers was 7.69%. There were three peaks of seizures: during the third trimester, during delivery and in the puerperium. The prevalence of miscarriages, post-term birth and the rate of caesarean section were significantly higher among the WWE than among the non-WWE (p=0.001; p<0.001; p=0.02). Parameters of neonates (birth weight, birth length, head-, and chest circumference) were significantly different between the WWE group and the non-WWE group (p=0.003, p<0.001, p<0.001, p<0.001) Conclusions - In contrast with recent publications, there were significant differences in the parameters of neonates between the two groups. Our results are in accordance with those of previous studies from the aspect of AED-related MCM, the elevated risk of miscarriages and pre-existing hypertension. ]

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[Pain relief in the neurologist’s view]


[Pain, on the basis of its anatomical origin, can be nociceptive (somatic, visceral) or neuropathic, that is, occuring as a direct consequence of a lesion or disease affecting the somatosensory system. The past few years’ epidemiological studies showed that chronic neuropathic pain affects 7-8% of the general population. Diagnosis of neuropathic pain can be established without instrumental examinations, with the help of validated tests that can be used by any physician. Neuropathic pain greatly deteriorates the patients’ quality of life, and the effect of traditional analgesics is insufficient for its treatment. Thus, it is important to know those treatment procedures and drugs that have been proved to be efficient for relieving neuropathic pain.]


[Pain management in rheumatology]

NAGY Katalin

[Pain is the most common symptom in rheumatology, which can be of mechanical or inflammatory origin, acute and chronic, nociceptive, neuropathic and psychogenic. Pain can be relieved by analgesics, nonsteroidal anti-inflammatory drugs, opioids, adjuvants and special drugs depending on the etiology, for example a gout attack can be stopped by colchicine. For pain relief, we use therapeutic guidelines of the World Health Organization (WHO), which recommends the use of analgesics, NSAIDs and adjuvants as the first step, weaker opioids as the second, and strong opioids as the third step. In rheumatology, the first step's drugs are generally used. If possible, NSAIDs should be administered briefly, potentially combined with analgesics and muscle relaxants. If pain management is insufficient, tramadol should be given. Pain relief in rheumatology also include the use of local and intraarticular injections, physiotherapy, TENS and balneotherapy. Complex therapies that combine the above mentioned methods is often more effective than the use of medications only.]

Clinical Neuroscience



[Purpose - To evaluate the efficacy and safety of gabapentin (GBP) in idiopathic or crypto/symptomatic partial epilepsy in adults. Methods - We performed a prospective open label add-on study in pharmacoresistant patients with simple or complex partial or generalized seizures of partial onset (at least four seizures per month). GBP was added to no more than two baseline antiepileptics and the efficacy was rated primarily according to the seizure frequency. The secondary efficacy parameters were the change in the seizure severity scores (measured by the NHS3 scale) and in the quailty of life (measured by the QUOLIE-31 questionnaire). GBP was added up to 1500-1600 mg per day in the titration period than an individual optimalization was allowed in any further visits. The follow-up period was three months. Population - Fourteen Hungarian epilepsy out-patient unit participated in the study. 72 patients were enrolled, GBP was applied in 63 persons (ITT population) and 57 completed the study. Results - A more than 50% decrease in seizure frequency was found in more than 70% of the patients in the third month. Among them just every third patient became seizure-free. Significant improvement appeared also in the severity of seizures and in the total score of the quality of life questionnaire. There was no difference either according to the etiology of the epilepsy or the seizure types. GBP was tolerated excellently. There was no need to decrease of the dosage of GBP and the side effects were mild and of transitory nature. Consequences - GBP appears to be a valuable antiepileptic drug considering its high efficacy and extremely favourable tolerance. While GBP also decreases the severity of the seizures, its complex effects result an improvement in the quality of life of the patients. The positive effects have been durable during the follow-up. Open label naturalistic studies of larger population are needed to clear the special indications of GBP in chronic partial epilepsies.]

Clinical Neuroscience

What is the real effect of pregabalin in patients with diabetic neuropathic pain? (Do patients suffer from less pain or do they less care about it?)

CAGDAS Erdogan, NEDIM Ongun, SELIM Tümkaya, HAKAN Alkan, NEŞE Öztürk

Objectives - Depression and anxiety are frequent in patients with chronic diseases such as diabetic neuropathic pain. The pain seems to be more severe in patients in whom depressive findings accompanied pain symptoms. Pregabalin was reported to have positive effects on anxiety and depression. This brings out the question, whether the pain relief effect of pregabalin is due to its analgesic effect or to its effects on mood? The aim of this study is to find out whether the positive effect of pregabalin in patients with diabetic neuropathic pain is limited to its effect on pain. Thus the question - do patients suffer from less pain or do they less care about pain? - should be answered. Methods - With this aim the NRS scores of 46 patients with diabetic neuropathic pain, whose HADS scores did not change with pregabalin treatment were compared with their baseline levels, retrospectively. Results - The NRS scores of the group were reduced with pregabalin treatment. Conclusion - This results suggests that the reduced pain in pregabalin treatment should be independent from its effects on depression and anxiety.

Clinical Neuroscience

Thrombocytopenia with gabapentin usage

ATAKLI Dilek, YUKSEL Burcu, AK Dogan Pelin, SARIAHMETOGLU Hande, SARI Hüseyin

Gabapentin is an antiepileptic drug approved for adjunctive therapy for partial seizures. We report a case of a patient who had thrombocytopenia with the dose of 2400 mg/day of gabapentin. The causal relationship between gabapentin and thrombocytopenia was revealed by dramatic increase in thrombocyte count following the cessation of the gabapentin treatment. To our knowledge, this is the first case report with a hematopoietic side effect of gabapentin.