6. Pharmacothérapie de la douleur neuropathique

Capsule pour l’action pour LM (2nd ed., 2013)

En présence de douleur neuropathique, dans la LM, il faut utiliser un protocole par étapes, à l’efficacité démontrée, et réévaluer le traitement chaque année.

Le problème:

Pratiques d’excellence fondées sur des preuves:

Étapes à suivre dans la pharmacothérapie de la douleur neuropathique:

• Première intention –> gabapentine, prégabaline
• Seconde intention –> inhibiteurs du recaptage de la sérotonine et de la noradrénaline (IRSN), lidocaïne topique
• Troisième intention –> opioïdes à libération lente, tramadol
• Quatrième intention –> lamotrigine, topiramate, acide valproïque, cannabinoïdes, méthadone

Des essais cliniques randomisés (ECR) ont montré que, dans la plupart des cas, les anticonvulsivants gabapentine et prégabaline maîtrisent la douleur neuropathique liée à la LM. Des essais sur les IRSN ont montré une baisse de la douleur neuropathique, mais on ne dispose d’aucune donnée sur la LM. On a démontré que la lidocaïne topique maîtrisait la douleur neuropathique localisée et que le tramadol et d’autres opioïdes soulageaient la douleur neuropathique liée à la LM chez certaines personnes. Les études sur l’efficacité des médicaments de quatrième intention sur la douleur neuropathique ont produit des résultats mitigés, mais elles ne comprenaient pas de personnes ayant une LM. L’efficacité des antidépresseurs tricycliques (p. ex. : amitriptyline, nortriptyline) à maîtriser la douleur dans cette population était mitigée.

La douleur liée à la LM est souvent résistante aux médicaments. La douleur neuropathique étant généralement sous-traitée dans la communauté, plusieurs auteurs suggèrent de diriger les patients atteints de douleurs réfractaires à des cliniques de la douleur de troisième ligne et de leur offrir une approche thérapeutique multidimensionnelle comprenant des thérapies alternatives et complémentaires.

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