Pharmacological management of neuropathic pain

1. Pharmacological management of neuropathic pain Imran Afzal ST1 Manorlands

2. 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

3. 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

4. NICE Recommendations What is the first line treatment for neuropathic pain in diabetic patient? • Tramadol • Amitryptiline • Duloxetine • Fentanyl • Ibuprofen

5. NICE Recommendations Which group of anti depressants duloxetine belongs to? • TCA • SSRIs • SNRI • MAO-I

6. NICE Recommendation • Which opioid NICE recommends to use as 3rd line treatment for neuropathic pain? • MST • Fentanyl • Buprenorphine • Tramadol • Oxycodone

7. 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

8. NICE Recommendations-Key principles • Consider referring to specialist pain service if • Pain is severe • Pain substantially limits daily activities • Underlying health condition deteriorated

9. 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

10. NICE Recommendations-Key principles • Continue existing treatment if pain controlled • Respond to person’s concerns & expectations • Explain dose titration, give written advice if possible

11. 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

12. NICE Guidelines FIRST LINE TREATMENT • 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

13. NICE Guidelines FIRST LINE TREATMENT • 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

14. NICE Guidelines SECOND LINE TREATMENT 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

15. NICE Guidelines THIRD LINE TREATMENT 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

16. 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

17. Questions? • Thank you!