NICE clinical guideline 177 – Osteoarthritis: Paracetamol and/or topical NSAIDs should be offered to patients with knee or hand osteoarthritis before considering oral NSAIDs, COX-2 inhibitors or opioids.
Treatment should be reviewed after two weeks and stopped if not effective.
(Lidocaine 2.5% w/w with prilocaine 2.5% w/w)
- Cream 30g, 5g (£2.25 = 5g)
- Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients)
- May be helpful on sensitive skin
Lidocaine 700mg (5% w/w) medicated plaster
- Post-herpetic neuralgia only (see Management of neuropathic pain) (but see notes below)
- Not to be used for non-neuropathic pain e.g. fibromyalgia, musculoskeletal pain, headache etc.
- Apply once daily for up to 12 hours, followed by a 12-hour plaster-free period; discontinue if no response after 4 weeks; up to 3 plasters may be used to cover large areas; plasters may be cut.
- Following national guidance from NHS England, not recommended for initiation in primary care. Click here for more information
- Only indicated for the treatment of post-herpetic neuralgia, following initiation by specialist pain team
- Lidocaine plasters are only licensed for use in post herpetic neuralgia; there is a paucity of data from double blind RCTs demonstrating efficacy in other neuropathic conditions. Pain specialists may occasionally recommend a trial of lidocaine plasters in difficult to treat cases of other forms of neuropathic pain. If successful, GPs may be asked to continue prescribing with ongoing review from pain specialists
- Lidocaine plasters can result in gradual desensitisation of the nerves, leading to improvement in symptoms; the plaster may be discontinued if this should occur. Prescribers should therefore consider a trial withdrawal of therapy to reassess ongoing need at appropriate intervals
- Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)
- Zacin® cream containing 0.025% capsaicin (£17.71 = 45g)
- Axsain® cream containing 0.075% capsaicin (£14.58 = 45g)
- Capsaiscin 0.025% is licensed for the symptomatic relief of osteoarthritis. It may need to be used for 1-2 weeks before pain is relieved
- Capsaicin 0.075% cream is licensed for the symptomatic relief of postherpetic neuralgia after lesions have healed, and for the relief of painful diabetic neuropathy
- Topical capsaicin has been included for use although trial data is poor and its place is uncertain in pain relief
- Qutenza® patches, self-adhesive capsaicin 179mg (8%)
- Use of capsaicin (8%) patch (Qutenza®) for neuropathic pain is commissioned within its licensed indication of peripheral neuropathic pain in non-diabetic patients, only after conventional oral and topical therapies as described in NICE CG96 have proven unsuccessful. Commissioning is restricted to its use in specialist secondary care pain clinics (see Commissioning Policy for more details).
10. Musculoskeletal & joint diseases >
10.3 Drugs for the treatment of soft-tissue disorders and topical pain relief >
10.3.3 Topical analgesia and capsaicin
- First line
- Second line