Small fiber neuropathy pain treatment

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Ligament said:
Need some treatmemt pearls.

Any use for scs? IV ketamine?

I have a very legit patient suffering from this

Thx!!
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Where I did fellowship the neurologists had some studies going on looking at biopsy-proven small fiber neuropathy and high-intensity supervised exercise program (I think it was mostly aerobic exercise, but also lower extremity resistance exercises). They showed decreased pain and actually increased nerve density. (Sorry, I don’t have the reference)

I’d say definitely a role for stim but some of these patients have severe pain because of a low pain threshold and poor coping skills. Enforce lifestyle modifications first - smoking cessation, nutrition, and vigorous physical exercise. Maybe alpha-lipoid acid as a supplement. Send them for PT for work hardening or just a rigorous strengthening program. Educate them on how nerve pain doesn’t indicate physical damage to the area even though it feels like it. If they can’t do the PT because it “hurts too much” then send to pain psych for ongoing therapy. If they complete the exercise program with good participation but still have a lot of pain, send to pain psych for SCS clearance.

In fellowship we did an SCS for one of the former type (wasn’t my call and I didn’t know better at the time) and he was a thorn in our side for the rest of the year - great trial result but mediocre perm results. Kept coming to the ER because he couldn’t stand the pain, despite the stim.
 
Huge psyc overlay in most of this patient population. Tell them to learn to live with it. Avoid the headache of the scs
 
This particular patient is very young, has some genetic problems causing small fiber neuropathy as well as some other issues. No psych overlay.
 
Problem with IV ketamine is may work but just temporary... Unless you're willing to try nasal.

I remember in fellowship one responding very well to lidocaine infusion then mexiletine after failing other neuropathics. N of 1.

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The guru on this appears to be Charles Argoff in Albany, NY. There are one or two good podcasts done by him that are free on the PainWeek site. He talks quite a bit about skin biopsy and pharmacotherapy


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ragnathor said:
Problem with IV ketamine is may work but just temporary... Unless you're willing to try nasal.

I remember in fellowship one responding very well to lidocaine infusion then mexiletine after failing other neuropathics. N of 1.

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Click to expand...

We did a lot of iv lidocaine “challenges” during fellowship. Many responded favorably but almost no one responded to Mexiletine. Same for iv phentolamine and po terazosin.


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What's the underlying genetic mutation?

There's some new stuff coming in the pipeline that looks promising (Third Positive Phase 2 Proof-of-Concept Study for VX-150 Further Validates the Potential Role of NaV1.8 Inhibition)

In the mean time, I would optimize nerve health as best as possible. I would consider the anticonvulsants as they seem to work best for the positive burning/pain symptoms. Most of the drugs aren't great for this though. Once you get through the usual ones, the one to reach for would be lacosamide.

www.ncbi.nlm.nih.gov

Lacosamide in patients with Nav1.7 mutations-related small fibre neuropathy: a randomized controlled trial - PubMed

Symptomatic treatment of neuropathic pain in small fibre neuropathy is often disappointing. The finding of voltage-gated sodium channel mutations in small fibre neuropathy (with mutations in SCN9A, encoding for Nav1.7) being most frequently reported suggest a specific target for therapy. The...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
"The dose of lacosamide is increased weekly, starting with 50 mg BID in the first week, followed by 100 mg BID in the second week, and concluding with 150 mg BID in the third week. After these 3 weeks, the treatment phase begins for 8 weeks. Based on previous studies and on the dose-related side effects, a dose of 200 mg BID has been chosen as the maintenance dose."

I have done stim for this but it's not a slam dunk and the disease state is normally progressive.
I would prefer to use ziconotide for this as it had some weak data in animals for being neuroprotective and it makes sense for the NaV issues, but getting a pump into these types of patients is hard as they normally do have some psych issues.
 
I treat it like fibromyalgia. I think there's some evidence that fibromyalgia may actually just be a small fiber neuropathy. Anyway I use all the usual suspects, TCAs, Cymbalta, Savella, Lyrica, Flexeril, Tramadol, LDN etc.
 
To update my previous post, the real guru on SNF is Anna Louise Oaklander a neurologist at MGH. She has many relevant publications worth reading
 
eishirukofuko said:
I may be wrong but as I know nonsteroidal anti-inflammatory drugs (NSAIDs), such as Aleve and Motrin, are sometimes used to treat neuropathic pain.
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Thanks for the tip, I'll look into it
 
clubdeac said:
I treat it like fibromyalgia. I think there's some evidence that fibromyalgia may actually just be a small fiber neuropathy. Anyway I use all the usual suspects, TCAs, Cymbalta, Savella, Lyrica, Flexeril, Tramadol, LDN etc.
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glad to see someone else has LDN on their list of meds for fibro. not perfect but good to have in the toolbox for certain cases (neuropathic or psych trainwrecks for example).
 
Multimodal said:
glad to see someone else has LDN on their list of meds for fibro. not perfect but good to have in the toolbox for certain cases (neuropathic or psych trainwrecks for example).
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I’ve tried it, no idea if it’s voodoo or not
 
I haven't had great results with LDN and have been avoiding it due to the compounding cost for most folks. Where are you getting it from and how is it compounded exactly? Some of the LDN websites/forums claim a big difference in out comes with the way it is made, but I'm still not sure it works.
 
Orin said:
I haven't had great results with LDN and have been avoiding it due to the compounding cost for most folks. Where are you getting it from and how is it compounded exactly? Some of the LDN websites/forums claim a big difference in out comes with the way it is made, but I'm still not sure it works.
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50mg. 1/4 pill qd
 
lobelsteve said:
50mg. 1/4 pill qd
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Nice, so using the regular pill? The LDN protocols were for 4.5 mg or ~1/10th of that dose but I was debating trying that as it was a made up number.
 
Orin said:
I haven't had great results with LDN and have been avoiding it due to the compounding cost for most folks. Where are you getting it from and how is it compounded exactly? Some of the LDN websites/forums claim a big difference in out comes with the way it is made, but I'm still not sure it works.
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I use a fair amount of it, with mixed results. I consider getting a fibro patient off opiates a complete WIN, so I will continue to rx.

Most compounding pharmacies in my area charge about $1/day -a few mail order pharmacies I have found are slightly cheaper (will look in my mass of paperwork and post info when I get around to it)

I dose 1.0mg -4.5mg. The first month or two I rx 1.0mg pills and let the patient find "their dose"
 
Orin said:
Nice, so using the regular pill? The LDN protocols were for 4.5 mg or ~1/10th of that dose but I was debating trying that as it was a made up number.
Click to expand...
1/4 pill of 50mg is 12.5mg, or about 3x the 4.5mg dose. Plus loss due to splitting. Dirt cheap. And if placebo-harmless.
 
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