pharmacological management of neuropathic pain n.
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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


  • Thank you!