DrJEDtalks: Nerve pain and Meds. Short

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Hello, Dr.

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Jet here. Today we’re talking about nerve pain

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and the medical treatment of nerve pain.

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So in doctor speak, nerve pain is sometimes referred to

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as neuropathic pain, neurogenic pain,

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perhaps radicular pain.

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Radi means root as in nerve root.

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Cervical radicular pain

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or cervical radiculopathy would be a

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pinched nerve in the neck.

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Lumbar radiculopathy would be a pinched nerve.

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In the low back, uh, there is sometimes sciatica

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that’s essentially the same thing,

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a pinched nerve typically in the low back, causing pain down

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to the lower extremity.

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So the causes of nerve pain, there are many, many,

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many causes of nerve pain to begin with.

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You could divide them into overall two separate domains.

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Okay? One domain would be that of nerve entrapments,

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nerve impingement.

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That is the direct pinching of a nerve,

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the direct damage of a nerve.

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Uh, the pinching of a nerve might happen in the neck.

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Once again, that would be cervical radiculopathy,

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a pinched nerve in the neck, lumbar radiculopathy.

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O oftentimes you may use the, uh, term radicular pain

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or radiculitis if it doesn’t quite meet the threshold

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of true radiculopathy.

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Once again, uh, the threshold

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of radiculopathies would be focal sensory and

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or motor deficits backed up with some, uh, special testing

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that your Dr. May do.

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There are many in many other nerve entrapments,

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but, uh, that will suffice it for now

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for like a general discussion

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of the common nerve entrapments.

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Now, other potential causes of the entrapment,

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the direct injury of nerve pain could just be direct injury.

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Well, what if you fell down

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and you nailed your funny bone, really hard on a piece

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of steel that can cause nerve pain.

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Uh, similarly, trauma accidents. You break your arm.

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That can cause a direct nerve injury.

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Sometimes you can have a much delayed nerve injury.

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Say for example, if you break your humerus many,

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many years later, as the bone callous grows up,

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it can be begin to impinge upon a nerve

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and that it can eventually cause what’s called tardy palsy.

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Tardy means late so many, many causes

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of the nerve impingement,

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the nerve entrapments the direct nerve damage.

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So the other domain of nerve pain is the neuropathies.

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Neuropathy in general is simply a disease state

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that is adversely affecting the healthier nerves,

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and that translates to your nerves not conducting normally.

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Sometimes the messages make it up to your brain

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and interpret it all kinds of different ways.

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Other symptoms of the peripheral neuropathy can eventually

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include impaired proprioception.

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That is an impaired ability to understand

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where your feet are in space and time.

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There are a thousand known causes of a peripheral

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Neuropathy. Let’s

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go over the top few most common.

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So in America and most of the industrialized nations,

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it would go something like this for 1, 2, 3, diabetes,

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alcohol, and thyroid disease.

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So notice that number one is diabetes.

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Many and many people think, well,

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peripheral neuropathy equals diabetes.

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If I don’t have diabetes,

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I don’t have a peripheral neuropathy.

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No, no, no. There’s those 999 other causes

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of a peripheral neuropathy.

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So once again, diabetes, alcohol, thyroid disease,

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kidney disease, renal disease that would lead

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to electrolyte imbalances, which makes it difficult

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for your nerves to continue to function well.

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There are various autoimmune diseases

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where you essentially attack your own nerves

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and can induce a neuropathy.

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Some infections are known to cause a peripheral neuropathy.

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HIV has a well-defined peripheral neuropathy

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associated with that.

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Uh, also Lyme disease can be associated

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with peripheral neuropathies.

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Other potential causes

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of a peripheral neuropathy are various medications.

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Many medications are known to cause a peripheral neuropathy.

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Probably the most common offenders are

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chemotherapeutic agents

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and sometimes they cause collateral damage.

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And once again, the nerves do a very complex job

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and if they get damaged,

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then you have a peripheral neuropathy.

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So that leads us now to the toxic exposures.

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There are many and many toxic exposures

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that can cause a peripheral neuropathy.

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Some of these may be, uh, cleaning agents, uh,

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particularly cleaning solvents.

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They’re used to dissolve grease.

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Um, acrylamide is a known, uh, toxic agent

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that can cause a peripheral neuropathy.

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Um, other things such as adhesives.

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I could go and read out a whole list of 50 things

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that are known to cause a peripheral neuropathy.

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The thing is, if you have any doubt at all,

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make sure you use your protective equipment if you are

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working around any substances

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that you’re suspicious with at all.

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So to review, in general, causes

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of nerve pain may be from the neural entrapments,

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the pinched nerve in the, the neck, the low back,

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or other places in the body versus the neuropathies,

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peripheral neuropathy, diabetic peripheral neuropathy.

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So what do we do about this?

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Well, the treatment of nerve pain can be very difficult.

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Nerve pain can be very resistant to standard medications

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to treat pain such as ibuprofen.

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Tylenol doesn’t really seem to do much.

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Even the narcotic pain medicines don’t treat

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nerve pain very well.

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So what are the standard treatments for nerve pain?

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The primary medical treatments for neuropathic pain

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that is nerve pain are the big three.

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So, uh, the most commonly used is gabapentin followed

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not in two distant second by Lyrica,

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also called pregabalin, and then

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Cymbalta. Those would be the

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big three medications that can be used

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to treat neuropathic pain to treat nerve pain.

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Now for many

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and many people, gabapentin works pretty well

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to decrease the nerve pain.

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Um, I have seen one particular study that has suggests

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that maybe it doesn’t work that great,

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but anecdotally of the thousands of patients I’ve given it

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to, sure there are some patients it doesn’t work.

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But there are many and many patients it does work.

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Now let’s speak about gabapentin dosing.

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There are many and many and many and many

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and many steps to dosing gabapentin.

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Uh, daily max dose for gabapentin would be 3,600 milligrams.

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I typically abide by the mantra of start low and go slow.

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So I oftentimes implement gabapentin

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with the 100 milligrams.

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Uh, I typically begin dosing gabapentin

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with the 100 milligrams.

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I typically write for the bottle,

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may say take two, three times a day.

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I oftentimes advise patients to

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begin maybe taking just the bedtime dose at first

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because the most common side effect

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of gabapentin is sleepiness.

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It can make you very sleepy, uh, as the doses get higher.

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Sometimes people note cognitive side effects, meaning, uh,

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they say it word processing gets more difficult.

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Um, they just sometimes don’t feel

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as sharp as they would like to.

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So let’s begin low and then go slow.

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So those one hundreds maybe eventually dosing up

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to 200 milligrams three times a day.

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I want to convey another point here,

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and that is there’s no magic to dosing gabapentin.

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Okay? The dosing parameters of those 100 milligram tablets

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or capsules, uh, if it says take two, three times a day,

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if you find it sufficient that you take 200 milligrams

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of bedtime and maybe 100 milligrams in the morning time

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and that’s fine, then that’s fine.

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You don’t have to take all those doses of gabapentin.

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It’s completely acceptable.

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So let’s say you’ve dosed up,

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you’ve titrated up your gabapentin dosing

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to include 200 milligrams three times a day.

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You might come back and talk it over with your doctor.

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If you’re my patient, you’re coming back

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and you’re talking over with me,

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at which case we might increase the dose

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to the 300 milligram capsules.

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We might just say 300 milligram capsules three times a day.

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Alternately, we might just say 300 milligram capsules,

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and the bottle will say, take two, three times a day.

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And now this follows the same mantra, meaning you don’t have

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to jump right to taking 600, 600, 600.

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Maybe you take 300 in the morning, 300 middle a day,

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and then you take 600 at bedtime.

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Completely acceptable.

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Uh, I have some patients that maybe take something like that

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and then 900 milligrams at bedtime

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also completely acceptable.

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So let’s say for example, you come back to your doctor

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after a month or so of trying that gabapentin dosing up

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to 600 milligrams three times a day.

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That would be a total dose of 1800 milligrams per day,

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which is a reasonable dose.

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By the time you’re taking 1800 milligrams a day,

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you might truly be decreasing

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that neuropathic pain that you’ve been experiencing.

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Let’s say for example, maybe it’s making a difference,

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but maybe not quite enough.

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You might titrate it up a little bit more,

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and that would be maybe the 900

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milligrams three times a day.

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I rarely go above that dose, uh, occasionally

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to 900 milligrams four times a day,

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or 1200 milligrams three times a day.

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And that would take you to the max dose,

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which would be 3,600 milligrams

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for the daily max dose for gabapentin.

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Let’s say for example, you get up there someplace 2,400

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milligrams a day or greater

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and it’s just not working for you

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or you are having side effects.

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You say, Hey doc,

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I just have trouble waking up in the morning,

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staying focused at work.

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I can’t do some of the cognitive tasks that I need to.

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Then your physician then has the information to put in the,

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in the chart note to get you Lyrica, uh, lyrica

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slash pregabalin.

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I term it oftentimes as gabapentin’s new

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and improved cousin is supposed to be cleaner,

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have fewer side effects, maybe work better,

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and that’s not always the case.

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I have had some patients that had titrated up, Lyrica,

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wasn’t working for them, went back to gabapentin,

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and gabapentin seem to be the better medicine.

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However, in general, it seems

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that Lyrica is a little cleaner.

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Fewer side effects works a little bit better.

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So the dosing on Lyrica is very different.

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Uh, the max daily dose four Lyrica is 600

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milligrams per day.

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Uh, oftentimes if a person has not had Lyrica yet,

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I’ll begin maybe the 25 milligrams three times a day.

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Uh, maybe at the 50 milligrams three times a day.

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So once again, you titrate this up to effect, okay?

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So you might take that, uh,

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50 milligrams once in the morning and once in the evening,

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and maybe for those first few days, if you take,

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if you took it all three times,

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maybe you were very sleepy in the afternoon.

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So perhaps it works best for you

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to take 50 milligrams in the morning

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and then 100 milligrams at bedtime so

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that you can get a good night’s sleep,

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whatever the case may be,

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50 milligrams three times a day, that’s reasonable.

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Say for example, you’re taking that dose,

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it’s helping a little bit, but not enough.

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You come back to your doctor,

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you have the talk, you can increase.

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Maybe you just go to 75 milligrams three times a day.

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Maybe you go to 100 milligrams three times a day.

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There’s no particular magic.

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There’s a discussion with your physician

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and then you advance as appropriate, uh,

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as a team working together.

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Okay? Eventually you might get get up as high as

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100 milligrams three times a day,

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150 milligrams three times a day.

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That used to be the max dose

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of Lyrica is 450 milligrams, uh, per day.

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These days, the max daily dose for Lyrica is 600 milligrams.

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So you might take 200 milligrams three times a day.

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I do have a couple patients

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that take 300 milligrams twice a day, sticking within that,

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uh, cap of 600 milligrams of Lyrica for the day.

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Now, the last medicine, Cymbalta, there’s some literature

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that suggests that Cymbalta may be the single best

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medication to treat neuropathic pain.

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So why don’t I begin with Cymbalta? Many reasons.

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Some of the main reasons might be just

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insurance stipulations.

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Myself, I’m a physiatrist. I’m not a psychiatrist.

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Psychiatrist oftentimes use Cymbalta

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to perhaps treat depression and

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or other various mood disorders.

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However, as that is not in my wheelhouse, I’m using Cymbalta

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to treat neuropathic pain.

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Typically, the guidelines that are placed there by insurance

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stipulate that I must try other medications first, try

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and fail other medications

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before they will approve Cymbalta.

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So that will oftentimes include dosing

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and trialing the gabapentin,

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sometimes going up trying the Lyrica.

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And if a person is still having neuropathic pain,

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then progressing to the Cymbalta.

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Cymbalta dosing is a little bit different.

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It is oftentimes dosed either once daily or twice daily.

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I typically do it twice daily myself.

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’cause once again, I’m trying to treat neuropathic pain

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and not a mood disorder.

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I’ll begin very low.

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Say for example, Cymbalta 20 milligrams twice a day,

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maybe do that for a month.

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You come back, we might go to 30 milligrams twice a day.

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You might go to 40 milligrams twice a day,

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up to 80 milligrams.

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Occasionally some patients will want to switch over

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to 80 milligrams once a day.

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In that case, that is acceptable in

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that case, nothing wrong with that.

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And, um, once you’re at 80 milligrams, there is, uh,

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literature that suggests that increasing the dose beyond

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that won’t make much of a difference in decreasing the pain.

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However, I have a couple patients that say

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otherwise that say that once they got to 120 milligrams,

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it made a big difference for them.

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However, in general, once you’re up

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to 80 milligrams a day on Cymbalta,

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you’re probably not gonna get much more benefit in

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decreasing that neuropathic pain.

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Now, there are many other specific treatments

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for neuropathic pain.

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However, those are very specific

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to very specific pathologies.

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In particular, specific to cases

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of pinched nerves in the neck

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or the back where you may be a candidate for injections.

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Similarly, there in both in the, uh, low back,

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particularly people may be a

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Candidate for what’s called a spinal cord stimulator.

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There’s also evolving technology

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of peripheral nerve stimulators.

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All these things continue to advance

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and continue to offer more options for the treatment

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of neuropathic pain, which once again,

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is very difficult to treat.

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If you have neuropathic pain, you begin with gabapentin,

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Lyrica, Cymbalta.

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If you continue to have neuropathic pain, you speak

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with your physician and see if there are other options

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that you can treat your neuropathic pain

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to help you live your life, less pain,

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improve your function, improve your mood,

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just improve your quality of life.

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So hopefully you find this helpful.

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Once again, continue to take care of yourselves and be well.