Neuropathic Pain
Common examples include painful diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia. 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 resistant to many medications and because of the adverse effects associated with effective medications. Drugs used in the management of neuropathic pain include antidepressants, anti-epileptic (anticonvulsant) drugs and opioids.
Overall prevalence estimated at 1-2%. Painful neuropathy in 20% diabetics. Post herpetic neuralgia >10%.
First line treatment
First line treatment: Oral Amitriptyline or Pregabalin
- Amitriptyline: start at 10 mg/day; gradually titrate to maximum of 75 mg/day
- Pregabalin: start at 150 mg/day (two doses); titrate to maximum of 600 mg/day
First line treatment in diabetic: Oral Duloxetine (oral amitriptyline if Duloxetine contraindicated)
- Duloxetine: start at 60 mg/day; titrate to effective dose or maximum 120 mg/day
Second line treatment
Trial new agent or in combination with a first line drug.
For non-diabetic patients
- If first-line treatment was with amitriptyline, switch to or combine with oral pregabalin.
- If first-line treatment was with pregabalin, switch to or combine with oral amitriptyline.
For people with painful diabetic neuropathy:
- If first-line treatment was with duloxetine, switch to amitriptyline or pregabalin, or combine with pregabalin.
- If first-line treatment was with amitriptyline, switch to or combine with pregabalin.
Third Line Treatment
If satisfactory pain reduction is not achieved with second-line treatment:
Refer the person to a specialist pain service. While awaiting referral:
- Consider oral Tramadol as third-line treatment instead of or in combination with the second-line treatment.
- Consider topical Lignocaine for treatment of localised pain for people who are unable to take oral medication because of medical conditions and/or disability.
The combination of Tramadol with amitriptyline, Nortriptyline, Imipramine or duloxetine is associated with only a low risk of serotonin syndrome (the features of which include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus). Topical Lidocaine is licensed for post-herpetic neuralgia, but not for other neuropathic pain conditions.
Links
UK National Institute for Health and Clinical Excellence
NHS Evidence - neurological conditions
NICE CG96 Pharmacological Management Neuropathic Pain Quick Ref. Local Copy.
