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Aim: Chronic postthoracotomy pain (CPTP) seems to be a combination of both nociceptive and neuropathic pain. The mechanism of CPTP based on neuropathic origin results in amitryptiline and gabapentine to be regarded attractive adjuvant analgesics. Aim of this trial is to compare the efficacy of gabapentine and amitryptiline in CPTP. Material and Method: 40 patients with chronic nonmalignant postthoracotomy pain (burning, stabbing and shooting pain) received gabapentine or amitryptiline as a single drug therapy. Study drugs were increased to effective and tolerable doses gradually throughout the study (4 weeks). Assessment variables were the intensity of burning, stabbing and shooting pain (assessed on VAS), side effects and patients' satisfaction (assessed with 7-points Likert's scale). The assessments were done before the study drugs treatments, at one and 4 weeks of study. Results: The burning, stabbing and shooting pain scores mean VAS values were lower in gabapentine group compared with amitryptiline group (p<0,05). Side effects were also high (55 %) in amitryptiline group (p<0,001). Patients satisfaction measured with Likert's scale was statistically significantly high in gabapentine grup (6,35±0,7; 50 % improvements) compared with amitryptiline group (4,55±0,9; 25 %). Conclusion: Gabapentin appears safe and well tolerated when used for chronic postthoracotomy pain. Gabapentin as one of the first line agents used in neuropathic pain are preferable in postthoracotomy pain. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Effectiveness of antidepressants and antiepileptic drugs has already been demonstrated for migraine prophylaxis as monotherapy. In the present study, the efficacy and tolerability of amitriptyline and topiramate combination is examined in the prevention of migraine attacks, in comparison to the monotherapy of each drug. Methods: A total of 73 patients with migraine headache with or without aura are included in this single-center, double-blind, randomized, and controlled trial. Patients were assigned to receive topiramate alone, amitriptyline alone or a combination of these drugs. Frequency, duration and severity of migraine attacks, accompanied symptoms, depressive state, consumption of medications, side effects and patient satisfaction were evaluated. Results: All treatments resulted in significant improvements in all efficacy measures (p <0.001 for all comparisons). However, patients receiving combination treatment had higher patient satisfaction compared with other groups both at 8 and 12 weeks (p =0.006 and p <0.001, respectively). Patients receiving amitriptyline and combination treatments had better depression scores compared with the topiramate group. Combination group had fewer side effects with a less amount of amitriptyline consumption. Conclusion: Amitriptyline and topiramate combination may be beneficial for patients with migraine and comorbid depression, particularly in terms of side effects and associated displeasure due to monotherapy. [Copyright &y& Elsevier]

Abstract: Neuropathic cancer pain represents a major challenge. Treatment often requires adjuvant analgesics, including gabapentin, to complement the effects of opioids. This study aimed to compare the effectiveness and safety of gabapentin combined with an opioid versus opioid monotherapy for the management of neuropathic cancer pain. Seventy-five cancer patients who were receiving opioid therapy and reported sufficient pain relief of nociceptive, but not neuropathic, pain were enrolled. Sixty-three patients completed the study. Patients were randomized to one of the following treatment protocols: 1) gabapentin adjuvant to ongoing opioid treatment titrated according to pain response while opioid dose was kept constant (group GO), and 2) continuation of opioid monotherapy according to the World Health Organization treatment ladder approach (group OO). Changes in pain intensity, allodynia, and analgesic drug consumption were evaluated at Day 4 and Day 13. Side effects were also recorded. Both treatments resulted in a significant reduction of pain intensity at Day 4 and Day 13 compared to baseline. However, mean pain intensity for burning and shooting pain was significantly higher in the OO group compared to the GO group at both the fourth (P =0.0001) and 13th (P =0.0001) days of the study. An earlier significant decrease (at Day 4, P =0.002) was observed for allodynia in the GO group compared to the OO group. The rate of side effects in the GO group was significantly lower than that in the OO group (P =0.015). These data suggest that gabapentin added to an opioid provides better relief of neuropathic pain in cancer patients than opioid monotherapy; this combination of gabapentin and an opioid may represent a potential first-line regimen for the management of pain in these patients. [Copyright &y& Elsevier]

Aim: The aim of this prospective, randomized, double-blind study was to evaluate whether adding metamizol to tramadol in an i.v. patient controlled analgesia (PCA) system improved the analgesic efficacy compared to i.v. PCA with tramadol plus metamizol administered when needed. Methods: Forty-six adult patients undergoing elective hemicolectomy were randomly assigned to either a tramadol group (group T; n = 23) or a tramadol plus metamizol group (group TM; n = 23) for postoperative pain treatment. Loading doses of i.v. 100 mg tramadol (group T) or i.v. 100 mg tramadol plus 1000 mg metamizol (group TM) were administered intra-operatively. Postoperatively, the PCA pump was programmed to deliver, on demand, doses of tramadol 20 mg (group T) or tramadol 20 mg plus metamizol 200 mg (group TM) without any baseline infusion. Lock-out time was set to 5 min and the 4-h dose limit was 400 mg and 4000 mg for tramadol and metamizol, respectively. Group T patients received i.v. metamizol when necessary as a rescue medication. Pain intensity (NRS), patient satisfaction, tramadol consumption and side effects were the outcome measures. Results: The first effective pain relief was reached at 4 h in group TM patients (NRS in group TM, 3.22; in group T, 4.57; P < 0.001); however, beyond 4 h. pain relief was similar. The incidence and severity score of postoperative nausea and vomiting were low in the TM group (P < 0.05). There were no significant differences between groups in terms of patient satisfaction. Conclusions: Tramadol combined with metamizol in a concentration of 1:10 mg in the PCA system provided slightly earlier pain relief and a decrease in the nausea/vomiting score compared to tramadol PCA plus, when needed, metamizol. Adding metamizol to a PCA system may be a practical and convenient option for postoperative analgesia. [ABSTRACT FROM AUTHOR]

Objectives: Suprascapular nerve block has been shown to be effective in acute, postoperative and chronic shoulder pain. The understanding of providing analgesia without destruction of neural tissue makes pulsed radiofrequency (PRF) lesioning attractive as a nondestructive method. In this study, the effectiveness of suprascapular PRF in chronic shoulder pain in both the short- and long-term was assessed., Methods: Forty patients suffering from shoulder pain of at least two months' duration, diagnosed with rotator cuff rupture by MRI scanning and with no response to systemic or physical therapy, were enrolled. After a favorable response to a diagnostic suprascapular nerve block, PRF application was done. Pain assessment was done using a standardized 7-point Likert scale and shoulder joint function assessment by Oxford Shoulder Score (OSS). The outcome measures were assessed in the third week as short-term and in six months as long-term., Results: Thirty-two patients completed the study. Eight patients were excluded from the study because of vagotony due to sitting position (20%). In comparison with baseline, Likert score of chronic shoulder pain was good (6.73+/-0.78; 6.50+/-1.07) (for both, p=0.000) and mean OSS was 16.28+/-3.15; 13.81+/-2.23 (for both, p<0.001) in the two assessment periods., Conclusion: Suprascapular nerve PRF lesioning was effective in chronic shoulder pain of rotator cuff lesion, and this effect was maintained in the long-term period. The improvement in shoulder joint function in parallel with decreased chronic shoulder pain was also notable.

In this single center, double blind and randomized trial gabapentin as a new anticonvulsant was compared in efficacy and safety with amitriptyline which is a classic agent in neuropathic pain treatment. Fourty six patients with neuropathic pain which was burning, stabbing and shooting in quality were allocated to take gabapentin (group GBP) and amitriptyline (group AMI) monotherapy. The assesment variables were burning, stabbing, shooting pain on visual analog scale (VAS; 0: no pain, 10: worst pain imaginable), allodynia as present or not by lightly touching the skin with cotton. Primary efficacy variable was the degree of burning, stabbing and shooting pain improvement that was accepted as the difference of beginning and 4th week's VAS of all pain qualities. The secondary efficacy variable was the patient satisfaction scale determined as whether possible side effects of study drugs affect the patients' daily life. The degree of pain improvement was only seen in shooting pain and was statistically significantly high in group GBP. The patient satisfaction scale was also high in group GBP. Both gabapentin and amitriptyline provided effective pain control in peripheral neuropathic pain. Additionally gabapentin was more effective especially in paroxysmal shooting pain than other pain qualities. And also gabapentin was tolerated well.

Tramadol, a centrally acting analgesic, consists of two enantiomers, both of which contribute to analgesic activity via different mechanisms. (+) Tramadol and the metabolite (+) -O- desmethyl-tramadol (M1) are agonists of the mu opioid receptor. (+) Tramadol also stimulates presinaptic release of serotonin and inhibits serotonin reuptake whereas (-) tramadol inhibits norepinephrine reuptake. Thus tramadol enhances inhibitory effects on pain transmission both by opioid and monoaminergic mechanisms. The complementary and synergistic actions of the two enantiomers improve the analgesic efficacy and tolerability profile of the racemate. Following oral administration the bioavailability of tramadol is high and with new slow release preparations twice daily administration enables effective pain control. The recommended maximum daily dose of tramadol is 400 mg/day. Tramadol is characterised by low plasma protein binding and quite extensive tissue distribution. Elimination is primarily by the hepatic route (metabolism by CYP2D6) and partly by the renal route. It is effective in different types of moderate-to-severe acute and chronic pain, including neuropathic pain, low back pain, osteoarthritis pain and breakthrough pain. It also causes fewer opioid-type adverse effects, e.g. nausea, drowsiness, vomiting, dry mouth and constipation. Although trials in literature demonstrate immune-stimulating effects of tramadol, there are also trials suggesting immunesuppressive effects that are lesser than morphine. Owing to its pharmacological properties, tramadol is more appropriate than NSAIDs for patients suffering from gastrointestinal and renal problems. Besides its proven clinical efficacy tramadol is a safe drug as respiratory depression, cardiovascular side effects, drug abuse and dependence are of minor clinical relevance, unlike some other opioids.