Pharmacological management of neuropathic pain
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Pharmacological management of neuropathic pain . Imran Afzal ST1 Manorlands . Presentation Layout. MCQs Why read summary of NICE guidance

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Presentation Transcript

Presentation layout
Presentation Layout

  • MCQs

  • Why read summary of NICE guidance

  • Neuropathic pain- incidence & current nonspecialist management problems

  • NICE Recommendations

  • Overcoming barriers- how and why it will change practice

Neuropathic pain
Neuropathic pain

What is the estimated prevalence of neuropathic pain in the UK?

  • 10-15 %

  • 5-10%

  • 1-2%

    Evidence: Bowsher et al Pain clinic 1991 telephone survey of 1037 households

Nice recommendations
NICE Recommendations

What is the first line treatment for neuropathic pain in diabetic patient?

  • Tramadol

  • Amitryptiline

  • Duloxetine

  • Fentanyl

  • Ibuprofen

Nice recommendations1
NICE Recommendations

Which group of anti depressants duloxetine belongs to?

  • TCA

  • SSRIs

  • SNRI

  • MAO-I

Nice recommendation
NICE Recommendation

  • Which opioid NICE recommends to use as 3rd line treatment for neuropathic pain?

  • MST

  • Fentanyl

  • Buprenorphine

  • Tramadol

  • Oxycodone

Neuropathic pain1
Neuropathic pain

  • Estimated prevalence: 1-2 % in UK

  • Often difficult to treat, resistant to many medications and all often have SEs

  • Currently treatment varies all over UK

  • NICE guidance for use in both primary and secondary care except specialist pain services

Nice recommendations key principles
NICE Recommendations-Key principles

  • Consider referring to specialist pain service if

  • Pain is severe

  • Pain substantially limits daily activities

  • Underlying health condition deteriorated

Nice recommendations key principles1
NICE Recommendations-Key principles

  • Taper or switch treatment slowly

  • Early clinical review on changing Rx

  • In regular clinical review assess

  • Pain reduction

  • SEs

  • Daily activities

  • Mood

  • Quality of sleep

  • Overall improvement

Nice recommendations key principles2
NICE Recommendations-Key principles

  • Continue existing treatment if pain controlled

  • Respond to person’s concerns & expectations

  • Explain dose titration, give written advice if possible

Nice recommendations key principles3
NICE Recommendations-Key principles

  • When selecting a drug consider

  • Person’s vulnerability including age, co-morbidity to SEs

  • Safety considerations and CIs

  • Patient’s preference

  • Lifestyle factors e.g., occupation

  • Mental health problems

  • Any other medication being taken

Nice guidelines
NICE Guidelines


  • Except for painful diabetic neuropathy offer oral amitrptyline or pregabalin

  • Amitriptyline: start at 10mg, gradually increase, max 75 mg/day

  • Pregabalin: start at 150 mg/ day in 2 doses, gradually increase, max 600mg/d

Nice guidelines1
NICE Guidelines


  • For painful diabetic neuropathy

    1. Offer duloxetine as first line

    Start at 60mg/day, slowly increase

    Max 120mg/day

    2. If duloxetine contraindicated e.g. uncontrolled BP or renal impairment

    offer oral amitryptiline

Nice guidelines2
NICE Guidelines


If pain reduction unsatisfactory and

  • Rx was amitryptiline , switch to/ combine pregabalin

  • Rx was pregabalin, switch to/combine amitryptiline

  • RX was duloxetine, switch to amitryptiline or pregabalin single or combined

Nice guidelines3
NICE Guidelines


If pain reduction not satisfactory with second line treatment

  • refer to specialist pain service and/or

  • consider oral tramadol alone or in combination with 2nd line treatment

    start tramadol at 50-100mg QDS

    max 400mg/d

  • For localized pain : topical lidocaine

Nice guidelines overcoming barriers
NICE Guidelines- Overcoming barriers

  • Currently various algorithms and guidelines in use , not consistent with NICE guidance

  • Implementing this will change practice especially for painful diabetic neuropathy

  • Previous guidelines did not use systematic and transparent evidence