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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:
Referral to the pain clinic for multidisciplinary pain management if there are persistent or distressing symptoms.
NICE CG173 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. 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.
Give an explanation and advice about the pain. Advise to maintain of normal activities and exercise. Treatment of depression or anxiety, pay attention to psychological and social factors (such as depression or joblessness) “yellow flags".
This is very important especially in Complex Regional Pain Syndrome to maintain function.
Some patients find this method effective. Machines are available over the counter. Patients will need to be taught how to use the TENS machine correctly, e.g. by the physiotherapy department.
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 over a period of time 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 need to 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.
Notes
If the first-line treatment detailed above is ineffective, after a trial of at least one month, duloxetine should be considered. Start duloxetine at 60mg per day (a lower starting dose may be appropriate for some people), with upward titration to an effective dose or the person's maximum tolerated dose of no higher than 120mg per day. 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.
(Lidocaine with prilocaine 25mg + 25mg)
Notes
Notes
The management of trigeminal neuralgia is distinct from other forms of neuropathic pain.