Rev. Soc. Esp. Dolor. 2021; 28(3): 137-147 / DOI: 10.20986/resed.2021.3911/2021
Ancor Serrano, Ana Navarro, Elena Paramés, Dolores Ochoa, Rafael Gálvez, Concepción Pérez
RESUMEN
Objetivos: Hace más de diez años que salieron al mercado los últimos fármacos con indicación en las guías internacionales de dolor neuropático (DN). Estas recomiendan iniciar con monoterapia y sitúan el tratamiento combinado en el segundo escalón. Un considerable número de pacientes no alcanza un suficiente alivio del dolor o mejora de su calidad de vida con los fármacos disponibles. Bajo esta perspectiva, el Grupo de Trabajo (GT) de DN de la Sociedad Española del Dolor (SED) diseñó una encuesta para el abordaje del DN mediante fármacos, técnicas intervencionistas y tratamientos fuera de indicación en nuestro medio. En este artículo se analiza solo la parte de tratamientos farmacológicos.
Material y métodos: Estudio descriptivo mediante un cuestionario autoadministrado difundido por correo electrónico a los socios de la SED en dos oleadas durante 2019. Al inicio del cuestionario se realizaba una pregunta de selección sobre si utilizaban o no tratamientos fuera de ficha técnica o fuera de indicación. Solo los que respondieron afirmativamente procedieron a todo el conjunto de preguntas. Este se dividió en los siguientes bloques: antiepilépticos, antidepresivos, antipsicóticos, anestésicos, anti-nmda, cannabinoides, naltrexona, tratamientos tópicos, toxina botulínica, polifarmacia y tratamientos fuera de ficha. Dentro de la sección de tratamientos tópicos se incluyó la toxina botulínica.
Resultados: La tasa de respuesta fue del 13,82 %, siendo del 10,05 % una vez descartadas las no válidas. El 21 % comienzan el tratamiento del DN con polifarmacia y un 43 % lo hace cuando no responden a una primera línea. El 40 % de los encuestados opinan que no hay evidencia suficiente para el uso de polifarmacia. El 70 % de los participantes trataban hasta un 30 % de sus pacientes con DN con fármacos fuera de indicación. El 23,3 % utilizaban medicamentos fuera de ficha técnica entre el 40 % y el 60 % de los pacientes con DN y un 6,6 % lo hacía en un 70-90 % de los pacientes. Los tratamientos fuera de indicación más frecuentemente utilizados según las respuestas obtenidas son, por orden: lidocaína al 5 % en parche, toxina botulínica, lidocaína en perfusión intravenosa y venlafaxina. Este orden se altera si se añaden los usados ocasionalmente, siendo en esta ocasión la venlafaxina la más utilizada, seguida por los anteriores en el mismo orden.
Conclusiones: Según nuestro conocimiento, esta es la primera vez que se realiza una investigación sobre el abordaje del DN con el objetivo de conocer la necesidad de polifarmacia y de utilizar fármacos fuera de indicación. A pesar de ser solo un estudio descriptivo, pone de manifiesto el gap entre las guías clínicas en DN, las publicaciones en revistas y la realidad en la práctica clínica diaria. Llama la atención que en varios grupos de fármacos existe discrepancia entre la utilización de alguno de ellos y el razonamiento sobre ese uso basado en publicaciones, versus a las publicaciones actualmente existentes. Así pues, creemos que la información obtenida, aun teniendo un peso relativo, es de suma importancia para poder entender el abordaje del DN en nuestro entorno.
ABSTRACT
Objectives: Latest drugs with an indication for neuropathic pain (NP) in the international guidelines came onto the market more than ten years ago. They recommend starting with monotherapy and place the combined treatment in the second step. A considerable number of patients do not achieve sufficient pain relief or improvement in their quality of life with the available drugs. From this perspective, the NP Working Group (WG) of the Spanish Pain Society (SED) designed a survey to address how NP drugs, off-label treatments and interventional techniques are being used in our setting. In this article we will only discuss the pharmacological treatment options.
Material and methods: Descriptive study using a self-administered questionnaire distributed by email to SED members in two waves during 2019. At the beginning of the questionnaire, a selection question was asked whether or not they used non-technical or off-label treatments. Only those who answered affirmatively proceeded to the entire set of questions. It was divided into the following blocks: antiepileptics, antidepressants, antipsychotics, anesthetics, anti-nmda, cannabinoids, naltrexone, topical treatments, botulinum toxin, polypharmacy and off-label treatments. Botulinum toxin was included in the topical treatments section.
Results: The response rate was 13.82 %, being 10.05 % once the invalid ones had been ruled out. 21 % begin the treatment of NP directly on polypharmacy and 43 % do so when they do not respond to a first line. 40 % of those surveyed think that there is insufficient evidence for the use of polypharmacy. 70 % of the participants treated up to 30 % of their NP patients with off-label drugs. 23.3 % used off-label medications in between 40 % and 60 % of patients with NP and 6.6 % did so in 70-90 % of patients. The most frequently used off-label treatments according to the responses obtained are, in order: 5 % lidocaine patch, botulinum toxin, lidocaine intravenous infusion, and venlafaxine. This order is altered if those used occasionally are added, this time venlafaxine being the most used, followed by the previous ones in the same order.
Conclusion: To our knowledge, this is the first time that research has been carried out on the approach to NP with the aim of knowing the need for polypharmacy and the use of off-label drugs. Despite being only a descriptive study, it highlights the gap between clinical guidelines in NP, publications in journals and the reality in daily clinical practice. It is noteworthy that in several groups of drugs there is a discrepancy between the use of some of them and the reasoning about that use based on publications, versus the currently existing publications. Thus, we believe that the information obtained, even having a relative weight, is of utmost importance in order to understand the approach to NP in our environment.
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