Following the publication of Nice guidelines on the pharmacological management of neuropathic pain, Gavin Atkin explains what you need to know
Nice guidance published in March outlines the recommended approach to managing patients suffering from neuropathic pain in primary care, and also hospital care where no specialist pain service is immediately available. A wide range of drugs is used to manage neuropathic pain, including antidepressants, anti-epileptics (anticonvulsants), opioids and topical treatments such as capsaicin and lidocaine. Many patients require treatment with more than one drug, but the correct choice of drugs and the order in which they should be used has been unclear, not least because guidelines in this area have been inconsistent.
1. Neuropathic pain arises from damaged or dysfunctional nerves, and can be due to a range of disorders affecting the peripheral and central nervous systems, including diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia.
2. People with neuropathic pain may experience altered pain sensation, areas of numbness or burning, and continuous or intermittent evoked or spontaneous pain. Neuropathic pain is an unpleasant sensory and emotional experience that can have a significant impact on a person’s quality of life.
3. Neuropathic pain remains difficult to treat because it is resistant to many medications and the effective treatments have adverse effects.
4. Patients should be referred to a specialist pain clinic or disease-specific specialist at any stage if their pain is severe or limits daily activities, or their underlying health deteriorates.
5. Patients’ concerns and expectations should be addressed when agreeing which treatments to use, and these are likely to include the benefits and possible adverse effects of pharmacological treatment, coping strategies for dealing with pain and the adverse effects of drugs, and non-pharmacological treatments including surgery and psychological therapies.
6. The selection of treatments should take comorbidities, safety issues and contraindications into account, as well as mental health problems. The titration process must be explained, and when withdrawing or switching treatment, doses should be tapered. Clinicians should consider overlapping treatments to maintain the pain control.
7. Patients should be reviewed shortly after a change in treatment to ensure it is suitable, and should be reviewed regularly.
8. In patients where the source of pain is not associated with diabetes, the first-line treatments are oral amitriptyline starting at 10mg/day gradually titrated upward to the maximum tolerated dose up to 75mg/day, or pregabalin starting at 150mg/day (or less in some patients) in two daily doses with upward titration to the patient’s maximum tolerated dose of no higher than 600mg/day. If satisfactory pain reduction is not achieved with first-line treatment at the maximum tolerated dose, the patient should be referred to a pain clinic or offered another drug in addition or as an alternative to their first-line treatment. The third-line options are oral tramadol and topical lidocaine.
9. In patients whose pain is due to diabetic neuropathy, oral duloxetine should be offered as a first-line treatment, starting at 60mg/day (less in some patients). Where duloxetine is contraindicated, amitryptyline should be offered.
10. If amitryptyline proves effective but the patient is unable to tolerate its adverse effects, oral imipramine or nortriptyline should be considered.
Reference: Neuropathic pain pharmacological management, http://guidance.nice.org.uk/CG96
Tips for your CPD entry on neuropathic pain management
Reflect Do I understand current guidance on the pharmacological management of neuropathic pain?
Plan Assess which aspects of neuropathic pain management you are least clear about
Act Read this article and the relevant sections of the Nice guidance (see reference above)
Evaluate Can I advise GPs and patients on drug treatment for neuropathic pain?