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See NICE CG173 - Neuropathic pain - pharmacological management (November 2013)
Many different types of pathology may cause neuropathic pain – this heterogeneity results in a wide variety of mechanisms and presentations of pain, for example:
Use neuropathic pain screening questionnaires to make the diagnosis (LANNS, Pain detect, DN4).
Prior to starting treatment a pain score should be recorded in the notes. This can be a formal test such as the Brief Pain Inventory, or simple questions such as average and worst pain in last couple of weeks, and level of interference with quality of life. This information can be used to help review effectiveness of treatments at later dates.
The effectiveness of treatment should be established prior to continuing with the therapy. Some patients may be very reluctant to stop taking pregabalin as although it is not effective, it is the last drug to be tried and they are afraid to stop.
Discussion about the limited effectiveness of medication tried should be documented in the patient's notes prior to starting a trial of anti-neuropathic pain medication.
The NICE clinical guideline for neuropathic pain emphasises establishing an underlying diagnosis and initiating treatment (such as diabetes) and on tailoring pharmacological treatment to the individual.
Up to 40% of patients may be refractory to drug treatment, making a multidisciplinary approach to treatment desirable.
All anti-neuropathic pain medication should be reviewed regularly. Significant numbers of patients who find it initially helpful, will find the drug becomes less effective within a 6 month period.
If a patient is in severe pain while taking an analgesic, the effectiveness of that analgesic should be considered. The dose should be reduced and if there is no worsening of the pain, the dose reduction cycle should be repeated. Once a patient has been off the analgesic for a few weeks, it can be re-introduced to see if it is still effective. If there is worsening of pain on dose reduction, the previous dose should be prescribed, and a further review arranged in a few months.
Non-pharmacological treatments should be considered and the patient's co-morbidities taken into account when individually tailoring treatment. If diagnosis uncertain or pain is severe or has a significant impact on daily activities, consider referral to pain specialist or disease specific service if underlying condition clear.
Referral to the pain clinic for multidisciplinary pain management if there are persistent or distressing symptoms.
Psychological factors
Give an explanation and advice about the pain. Advise to maintain normal activities and exercise. Treatment of depression or anxiety, pay attention to psychological and social factors (such as depression or joblessness) “yellow flags".
Physiotherapy
This is very important especially to maintain function. Regular aerobic exercise has been shown to be beneficial in treating pain. If patients are fearful about the safety of exercise/find it difficult to start, advice can be sought from local pain clinics.
These drugs have a ceiling effect for pain relief and side effects. Unlike conventional analgesics their side effects are often noticed by the patient before the ceiling effect for pain relief is reached. Therefore the drugs should be given slowly and titrated upwards with careful monitoring of side effects.
In neuropathic pain, prescribing should be based on a patient's symptoms and signs i.e. mechanisms of pain rather than pathophysiological diagnosis.
In choosing pharmacological agents to treat consider patient co-morbidity, patient preference, occupation and mental health. Consider the following points:
Once established, frequent clinical reviews are required. Ideally 30-50% reduction in Visual Analogue Scale (VAS) pain score. However, also assess and record improvements in daily activities, patient global impression of improvement, sleep and mood. Dose should be titrated to achieve maximum benefit with minimum side effects.
refer to 4.3.1 Tricyclic and related antidepressant drugs
refer to 4.3.1 Tricyclic and related antidepressant drugs
refer to 4.8.1 Control of the epilepsies
Notes
Add in an alternative first line agent. Recent studies have shown gabapentin combined with a tricyclic has increased efficacy when compared to each agent alone.
refer to 4.8.1 Control of the epilepsies
refer to 4.3.4 Other antidepressant drugs
If the first-line treatment detailed above is ineffective, after a trial of at least one month, duloxetine should be considered.
Follow dosing schedule as above
Stop duloxetine if pain is not reduced by 30% at one month and consider pregabalin.
If second line treatment not effective, refer to specialist pain service and/or condition specific service e.g. oncology, neurology, diabetology.
refer to 4.7.2 Opioid analgesics
(Lidocaine with prilocaine 25mg + 25mg)
Notes
Notes
Sodium valproate (refer to 4.8.1 Control of the epilepsies), Topiramate (refer to 4.8.1 Control of the epilepsies) may be used under specialist advice. Also strong opioids, morphine or oxycodone (refer to 4.7.2 Opioid analgesics) and combination therapy with more than one agent.
(Nabilone may be used by South Devon Healthcare NHS Foundation Trust)
The management of trigeminal neuralgia is distinct from other forms of neuropathic pain.