Fallbeispiel „Burning mouth Symdrom“ erfolgreich behandelt mit Duloxetin

Duloxetine in the treatment of burning mouth syndrome refractory to conventional treatment: A case report

  1. Yeon-Dong Kim1
  2. Ji-Hye Lee2
  3. Jee-Hoon Shim1

  1. 1Department of Anaesthesiology and Pain Medicine, Wonkwang University Hospital, Ik-san, Republic of Korea
    2Department of Anaesthesiology and Pain Medicine, Chonbuk National University Hospital, Jeon-ju, Republic of Korea
  1. Dr Yeon-Dong Kim, Wonkwang University Hospital, 344-2 Sinyong-dong, Ik-san 570-749, Republic of Korea. Email: kydpain@hanmail.net

Zusammenfassung

Patienten mit brennendem Mund-Syndrom (BMS) berichten über Brennen und Schmerzen in der Zunge und der Mundschleimhaut ohne dass offensichtliche medizinische oder zahnärztliche Ursachen vorliegen. Die Pathogenese dieses Syndroms bleibt unklar und es gibt derzeit keine Standardbehandlung. Das BMS wird daher oft fehlerhaft diagnostiziert und sein Management ist schwierig. Dieser Mangel an klinischem Fachwissen kann zu einer verminderten Lebensqualität und einer erhöhten psychischen Belastung bei Patienten mit BMS führen. Der vorliegende Fallbericht präsentiert eine 77-jährige Patientin mit BMS, deren Beschwerden mit konventioneller Behandlung mit Nervenblock und Medikamenten nicht  zu lindern waren. Hier konnte sie erfolgreich mit Duloxetin behandelt werden. Duloxetin kann eine neue therapeutische Option im Management von BMS werden.

Case report

A 77-year-old female patient was transferred to the Department of Anaesthesiology and Pain Medicine, Wonkwang University Hospital, Ik-san, Republic of Korea in January 2012 from the Department of Oral Medicine in the same institute. She had complained of a burning sensation in her tongue and lower lip over the previous 2 years. Her medical history was unremarkable and she did not report any traumatic events. The patient described a severe burning sensation, with pain persisting throughout the day without any aggravating factors. Her level of pain was between 80 and 90 on a visual analogue scale (VAS) of 100 and she scored 40 of 45 on the short-form McGill Pain Questionnaire (SF-MPQ).9 The patient had visited dentists, internists, neurologists and neuropsychiatrists at several other clinics, but no effective treatment had been proposed. Prior to transfer to the present clinic, she had been treated with up to 1200 mg gabapentin (oral, three times a day) and 0.5 mg topical clonazepam (applied to the tongue, three to four times a day) for one month. She initially reported a reduction in pain by 20% (VAS score), however, the improvement was short-lived and gabapentin caused side effects (dizziness).

The results of laboratory tests were normal, including assessments of haemoglobin level (12.9 g/d [normal range, 12–16 g/d]), platelet count (255 × 103 µl [normal range, 150–450 × 103/µl]), white blood cell count (6.61 × 103/µl [normal, 4.10 × 103 cells/µl]), erythrocyte sedimentation rate (3 mm/h [normal range, 0–10 mm/h]), and C-reactive protein level (0.62 mg/l [normal, 0–5 mg/l)]. Test results for liver function (aspartate transaminase, 18 IU/l [normal, 5–35 IU/l]; alanine transaminase, 12 IU/l [normal, 5–40 IU/l]) and thyroid function (tri-iodothyronine, 100.16 ng/dl [normal, 60–190 ng/dl]; thyroxine, 7.79 µg/dl [normal, 4.5–12.0 µg/dl]; thyroid stimulating hormone, 3.66 µlU/ml [normal, 0.2–5.0 µlU/ml]), electrolyte levels (sodium, 136 mEq/l [normal, 135–150 mEq/l]; potassium, 4.5 mEq/l [normal 3.5–5.5 mEq/l]), serum ferritin levels (41.97 µg/l [normal 13–150 µg/l]), total iron-binding capacity, percent transferrin saturation, serum vitamin B12 (74.66 µg/l [normal, 13–150 µg/l]) and folic acid levels (8.58 µg/l [normal, 4.6–18.7 µg/l]) were also normal. Brain magnetic resonance imaging did not show any abnormalities. Extra- and intraoral examinations performed at the Department of Oral Medicine yielded normal results, with no alteration of quality (viscosity, resting pH of unstimulated saliva) or flow in the salivary function test. The patient did not meet the Tenth Revision of the International Classification of Diseases and Related Health Problems (http://www.who.int/classifications/icd/en/) for any psychiatric disorder and had no history of depression on psychiatric consultation. The patient was also found to have a normal score on the Beck Depression Inventory,10 which was completed while the clinical team took her full medical history; this finding indicated an absence of depression.

After diagnosing the patient with BMS, a nerve block was performed which comprised a stellate ganglion block (6 ml of 1% lidocaine) every 4 weeks and a lingual nerve block (4 ml of 1% lidocaine and 10 mg triamcinolone) bilaterally every 2 weeks, for a total of 4 weeks. The patient reported no side-effects. Her symptoms persisted, however, and treatment with 20 mg nortriptyline (oral, twice a day) and 600 mg carbamazepine (oral, three times a day) was administered for the following month. No beneficial clinical effects were observed, however, as the patient failed to adhere to the regimen because of somnolence. She was subsequently treated with an opioid (oxycodone/naloxone [Targin®]; Mundipharma Korea Ltd., Seoul, Korea) at a dose of 20 mg (oral, following breakfast) which increased to 40 mg (oral, twice a day), but no improvement in pain intensity was observed. Treatment with duloxetine was then initiated at a dose of 30 mg/day (oral, following breakfast) for 2 weeks followed by 60 mg/day (30 mg/oral, twice a day) for another 2 weeks. The patient’s symptoms gradually improved, and at 4 weeks of treatment her VAS pain score decreased to 50–60 and her SF-MPQ score decreased to 33. The patient continued to receive treatment for the following 3 months. At 4 months of treatment, her VAS score had decreased to 0–10 and her SF-MPQ to 6. The patient remained asymptomatic throughout a 16-month follow-up period.

 

Kommentar Joachim Wagner

Duloxetin – auch bekannt als Cymbalta – ist ein neuer vielversprechender Kandidat für die Behandlung trigeminaler neuropathischer Schmerzen. Die Anwendungszulassung in Deutschland umfasste bisher nur die Erkrankungen Depressionen und schwere Angstzustände. Wie ich aber aus eigener Erfahrung als Therapeut und vor dem Hintergrund des obigen Falles berichten kann, zeichnet sich allmählich eine weiteres Anwendungsgebiet bei chronischen Schmerzen im Trigeminusbereich ab. Auch gut ist: Die Risiken für unerwünschte und gefährliche Nebenwirkungen liegen niedriger als beim derzeitigen Standardmedikament Carbamazepin.

 

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