Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings

National Institute for Health and Clinical Excellence

Key principles of care

• Address the person’s concerns and expectations when agreeing which treatments to use by discussing:
  • benefits and possible adverse effects of each pharmacological treatment
  • why a particular pharmacological treatment is being offered
  • coping strategies for pain and for possible adverse effects of treatment
  • that non-pharmacological treatments are also available in non-specialist settings and/or through referral to specialist services (for example, surgical treatments and psychological therapies)
• When selecting pharmacological treatments, take into account:
  • the person’s vulnerability to specific adverse effects because of comorbidities
  • safety considerations and contraindications as detailed in the summary of product characteristics (SPC)
  • patient preference
  • lifestyle factors (such as occupation)
  • any mental health problems (such as depression and/or anxiety*)
  • any other medication the person is taking
• Explain both the importance of dosage titration and the titration process—provide written information if possible
• When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms
• When introducing a new treatment, consider overlap with old treatments to avoid deterioration in pain control
• Continue existing treatments for people whose neuropathic pain is already effectively managed^†

Drug dosages

• Start at a low dose, as indicated in the table
• Titrate upwards to an effective dose or the person’s maximum tolerated dose (no higher than the maximum dose listed in the table)

DRUG	STARTING DOSE	MAXIMUM DOSE
Amitriptyline ‡	10 mg/day	75 mg/daya
Pregabalin	150 mg/dayb (divided into 2 doses)	600 mg/day (divided into 2 doses)
Duloxetine	60 mg/dayb	120 mg/day
Tramadolc	50–100 mg not more often than every 4 hours	400 mg/day
‡ Not licensed for this indication at time of publication (March 2010). Informed consent should be obtained and documented a Higher doses could be considered in consultation with a specialist pain service b A lower starting dose may be appropriate for some people c As monotherapy. More conservative titration may be required if used as combination therapy

Other treatments

• Do not start treatment with opioids (such as morphine or oxycodone) other than tramadol without an assessment by a specialist pain service or a condition-specific service^§
• Other pharmacological treatments that are started by a specialist pain service or a condition-specific service^§may continue to be prescribed in non-specialist settings, with a multidisciplinary care plan, local shared care agreements and careful management of adverse effects

Early clinical review

• After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects to assess suitability of chosen treatment

Regular clinical reviews

• Perform regular clinical reviews to assess and monitor effectiveness of chosen treatment. Include assessment of:
• pain reduction
• adverse effects
• daily activities and participation^ı (such as ability to work and drive)
• mood (in particular, possible depression and/or anxiety*)
• quality of sleep
• overall improvement as reported by the person

 

^* Refer if necessary to the relevant NICE clinical guidelines
^† Note that there is currently no good-quality evidence on which to base specific recommendations for treating trigeminal neuralgia. The Guideline Development Group (GDG) expected that current routine practice will continue until new evidence is available
^§ A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology,diabetology and oncology services
^ı The World Health Organization ICF (International Classification of Functioning, Disability and Health) defines participation as ‘A person’s involvement in a life situation.’ It includes the following domains learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships,major life areas, community, and social and civil life