Treating neuropathic pain in MS

[doublevision1]

Dr. Kantor

What is your opinion of the effectiveness of each of the following meds to treat neuropathic pain in MS?

- pregabalin
- gabapentin
- amitriptyline
- nabilone
- sativex

Many of the forum members deal with chronic neuropathic pain.  Personally I am experiencing chronic cervical myelopathy in my upper left extremities, for which I am prescribed 3600mg per day gabapentin, 50mg per day amitriptyline.  After being on these high doses for the past year, I would say I get maybe 40 – 50% pain relief from these meds.  I realize this is a very difficult type of pain to treat, but wonder if something stronger and/or of a different combination might be worth trying to achieve greater relief.  

Could you comment briefly on the mechanism of action in the above meds and which ones are typically most effective, with the most tolerable side effects?

Also, are there other established or experimental meds for MS pain that you would recommend pursuing?

Thank you.

~doublevision~

[doublevision1]

Appreciate your comments, and wonder if you could expand on your thoughts re: cannabinoids: Sativex, etc.  Is there evidence of long term damage in using them to treat pain?  What do you believe to be the most serious and most likely risks?
Many of the long list of potential side effects are similar to other meds, so in what way do these particular drugs 'affect the brain' more negatively than others?  Wouldn't it be true to say that the antidepressants and anti-seizure meds also affect the brain?  Not to mention the DMD's.

[Dr. Daniel Kantor, MD]

Great question.

Unfortunately there are no comparitive trials of the above. I will however split them into categories:


Anti-seizure medication:

- pregabalin
- gabapentin


Antidepressant:

- amitriptyline


Cannibinoids:

- nabilone
- sativex


These are just a few of the multiple medications your doctor may use for neuropathic pain. Unfortunately because of the rules in this forum I cannot comment on all the off-label medications which we use, but suffice it to say there are many more and they usually  fall under the categories of anti-seizure medications and antidepressants.

I do not use cannibinoids, nor do I personally recommend them. As one patient in rural Pennsylvani said very correctly: "MS is a disease that affects the brain, so why would you want to take a medications that affects your brain?"