Korean J Pain.  2014 Jan;27(1):54-62. 10.3344/kjp.2014.27.1.54.

Intravenous Nefopam Reduces Postherpetic Neuralgia during the Titration of Oral Medications

• Joo YC
• Ko ES
• Cho JG
• Ok YM
• Jung GY
• Kim KH

• KMID: 2278203
• DOI: http://doi.org/10.3344/kjp.2014.27.1.54

Abstract

BACKGROUND
The recently known analgesic action mechanisms of nefopam (NFP) are similar to those of anticonvulsants and antidepressants in neuropathic pain treatment. It is difficult to prescribe high doses of oral neuropathic drugs without titration due to adverse effects. Unfortunately, there are few available intravenous analgesics for the immediate management of acute flare-ups of the chronic neuropathic pain. The aim of this study was to determine the additional analgesic effects for neuropathic pain of NFP and its adverse effects during the titration of oral medications for neuropathic pain among inpatients with postherpetic neuralgia (PHN).
METHODS
Eighty inpatients with PHN were randomly divided into either the NFP or normal saline (NS) groups. Each patient received a 3-day intravenous continuous infusion of either NFP with a consecutive dose reduction of 60, 40, and 20 mg/d, or NS simultaneously while dose titrations of oral medications for neuropathic pain gradually increased every 3 days. The efficacy of additional NFP was evaluated by using the neuropathic pain symptom inventory (NPSI) score for 12 days. Adverse effects were also recorded.
RESULTS
The median NPSI score was significantly lower in the NFP group from days 1 to 6 of hospitalization. The representative alleviating symptoms of pain after using NFP were both spontaneous and evoked neuropathic pain. Reported common adverse effects were nausea, dizziness, and somnolence, in order of frequency.
CONCLUSIONS
An intravenous continuous infusion of NFP reduces spontaneous and evoked neuropathic pain with tolerable adverse effects during the titration of oral medications in inpatients with PHN.

Keyword

anticonvulsants; antidepressants; nefopam; postherpetic neuralgia; titration

MeSH Terms

Analgesics
Anticonvulsants
Antidepressive Agents
Dizziness
Hospitalization
Humans
Inpatients
Nausea
Nefopam*
Neuralgia
Neuralgia, Postherpetic*
Analgesics
Anticonvulsants
Antidepressive Agents
Nefopam

Figure

• 

  Fig. 1 A schedule for the continuous infusion of nefopam with a consecutive dose reduction in hospitalized patients with postherpetic neuralgia while dose-escalating of oral medications. Each patient received a 3-day intravenous continuous infusion of either nefopam (NFP) with a consecutive dose reduction of 60, 40, and 20 mg/d or NS simultaneously while dose titrations of oral medications for neuropathic pain gradually increased every 3 days. A rescue analgesic, 10 mg of oral codeine, was given at each NPSI score VAS > 40 less than 5 times a day. The efficacy of additional NFP was evaluated by using the neuropathic pain symptom inventory (NPSI) score for 12 days. Adverse effects were also recorded. Discharge criteria after the 12-day-admission included: (1) NPSI score < 40%, (2) spontaneous pain < 3 h during the past 24 h, (3) pain attack < 5 times during the past 24 h, and (4) no serious adverse effects, including dizziness, somnolence, or ataxia.

• 

  Fig. 2 The median scores of the grade of duration of spontaneous pain (SP) and number of pain attack (PA) during study days. (A) *The grade by the duration of SP during the past 24 h was lower, and (B) *the grade of the number of PA during the past 24 h was lower in NFP group from the day 2 to 6 of hospitalization (P < 0.05 compared to those of NS group). All data are expressed SD ± error. NFP: nefopam, NS: normal saline. Grade by duration of SP: grade 1 (less than 1 h), grade 2 (between 1 and 3 h), grade 3 (between 4 and 7 h), grade 4 (8 and 12 h), and grade 5 (permanently). Grade by frequency of PA: grade 0 (no pain attack), grade 1 (between 1 and 5), grade 2 (between 6 and 10), grade 3 (between 11 and 20), and grade 4 (more than 20).

• 

  Fig. 3 Rescue medication requirement and consumption. *Higher requirement and consumption of average additional rescue medication showed in NS group from the day 1 to 6 of hospitalization (P < 0.05 compared to those of NFP group). All data are expressed mean ± SD.

• 

  Fig. 4 Adverse effects. *Nefopam (NFP) increased the frequency of dry mouth, dizziness, nausea and ataxia, in order of frequency, during the initial period of the study days 1 to 6 (P < 0.05 compared to those of normal saline [NS] group). There was no difference between the groups in overall frequencies of occurrence for each adverse effect. Dry mouth in both groups was an intolerable adverse effect which showed a never-decreasing and even-increasing symptom till the end of the study days.

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