An update on the pharmacological management of pain in patients with multiple sclerosis

ABSTRACT

Introduction

The prevalence of pain in Multiple Sclerosis (MS) is estimated to be between 29-86% depending on various stages of the disease. According to a recent mechanism-based classification, MS pain syndromes include ongoing extremity pain, trigeminal neuralgia, and Lhermitte’s phenomenon, painful tonic spasms and spasticity pain, pain associated with optic neuritis, musculoskeletal pain, migraine, and treatment-induced pain.

Area covered

Pharmacological approaches for MS pain include anticonvulsants, antidepressants, botulinum toxin, cannabinoids, muscle relaxants, opioid analgesics, and intrathecally administered baclofen. It has been reported that pharmacological treatments have poor efficacy and alarming side effects. For these reasons, non-pharmacological interventions, either alone or in combination with pharmacological treatments are commonly used in clinical practice. Examples of these interventions include electrical or chemical neurostimulation therapy, exercise, and psychological approaches. This is discussed in more detail herein.

Expert opinion

The management of MS pain can be challenging due to the natural course of the disease and the lack of a definite cure. Recommendations based on rigorous scientific methods for MS pain treatment are unavailable. Thus, clinicians should consider available treatment regimens based on efficacy, safety, cost, and the clinical complexity of the patient. The use of therapeutic approaches combining pharmacological and non-pharmacological treatments may help to reduce the risk of overuse and mitigate the complaint of simultaneous and multiple therapies.

KEYWORDS:

• Multiple sclerosis
• pain management
• drugs
• non pharmacological treatments

Declaration of interest

CG Chisari has received grants for congress participation from Almirall, Biogen Idec, Merck Serono, Novartis, Roche, Sanofi Genzyme, and Teva. E D’Amico has received grants for speaking activities from Bayer Schering, Biogen Idec, Merck Serono, Novartis, TEVA and grants for congress participation from Almirall, Bayer Schering, Biogen Idec, Merck Serono, Novartis, Roche, Sanofi Genzyme, and Teva. F Patti. has received honoraria for speaking activities from Almirall, Bayer Schering, Biogen Idec, Merck Serono, Novartis, Roche, Sanofi Genzyme, and Teva; he also served as advisory board member the following companies: Bayer Schering, Biogen Idec, Merck Serono, Novartis, Roche, Sanofi Genzyme, and Teva. Furthermore, he has also been funded by Pfizer and FISM for epidemiological studies; he also has received grants for congress participation from Almirall, Bayer Shering, Biogen Idec, Merck Serono, Novartis, Roche, Sanofi Genzyme, and Teva. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Article Highlights

• Pain syndromes are common in multiple sclerosis (MS), even early stages of the disease.

• Managing MS pain can be challenging mainly due to the disease course and lack of a definite cure for it.

• The mechanisms underlying pain in MS are uncertain, probably involving neuronal pathways influenced by internal and environmental factors.

• Anticonvulsants, antidepressants, cannabinoids, and opioids/opioid antagonists are the most frequently used classes of drugs to treat pain in MS.

• Non pharmacological interventions are also commonly used in clinical practice alone or in combination with drugs.

• Since recommendations for the treatment of pain in MS patients are to date not available, treatment decision-making process is usually based on personal clinical experience.

• In choosing a specific treatment regimen, clinicians should take into account the drug efficacy and safety profile, the costs, and the clinical complexity of the patient. This box summarizes key points contained in the article.

Additional information

Funding

This manuscript has not been funded.