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Tayside Neuropathic Pain Guidelines 8th of June 2011 West Park, Dundee. Dr Dietmar Hartmann MD FRCA FFPMRCA. Components of pain. nociception perception of pain suffering pain behaviour. Artist Statement

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Tayside Neuropathic Pain Guidelines

8th of June 2011 West Park, Dundee

Dr Dietmar Hartmann MD FRCA FFPMRCA

components of pain
Components of pain
  • nociception
  • perception of pain
  • suffering
  • pain behaviour

Artist Statement

I picture myself as the woman in the painting because I feel I am constantly fighting against a tidal wave of pain in order to achieve some quality of life. I am in danger of losing the fight and giving up.

types of pain
Types of pain
  • Nociceptive pain An appropiate physiologic response to painful stimuli via an intact nervous system
  • Neuropathic pain An inappropiate response caused by a dysfuntion in the nervous system
  • Common pain descriptors: burning, tingling, shooting or excessive sensitivity
  • Sensory examination: Allodynia (pain from an innocuous stimulus e.g.cotton wool), hyperalgesia (more pain than expected from a stimulus such as pinprick)
  • Note: many patients will have mixed pain syndromes, with nociceptive and neuropathic features, use this algorithm along with standard analgesics.
holistic assessment
Holistic Assessment
  • Consider the following when selecting antidepressant or anticonvulsant first-line therapy for Neuropathic pain.
      • Work/shift patterns
      • Poor sleep
      • Previous failed treatments
      • Responsibilities e.g. main carer/dependants/return to work issues
anticonvulsant gabapentin
Anticonvulsant – Gabapentin
  • Titrate according to dosing regime
  • Trial for at least 4 weeks

Consider if:

  • Contraindication to tricyclic antidepressant
  • Night sedation would be problematic (e.g. main carer, shift worker)
  • Poor drug tolerance, Gabapentin is often better tolerated than amitriptyline
tricyclic antidepressant amitriptyline
Tricyclic antidepressant – Amitriptyline
      • Titrate from a low dose (10- 20 mg)
      • Titrate for at least 4 weeks

Consider first line choice if:

  • Poor sleep
  • Poor compliance with medication (once daily dosage)
  • Polypharmacy specifically large numbers of tablets/day
anticonvulsant pregabalin
Anticonvulsant - Pregabalin
  • Use third line if not achieved adequate pain relief or not tolerated first and second line treatments with tricyclic antidepressant +/- gabapentin
  • Can be used in combination with a tricyclic antidepressant 
  • Not to be co-prescribed with gabapentin
  • Titrate slowly according to dosing regime

Neuropathic pain

Implementing NICE guidance

March 2010

NICE clinical guideline 96

first line treatment diabetic neuropathy
Offer oral duloxetine: start at 60 mg/day (a lower starting dose may be appropriate for some people); titrate to effective dose or maximum tolerated dose – maximum 120 mg/day

If duloxetine is contraindicated, offer oral amitriptyline*

First-line treatment:diabetic neuropathy
multidisciplinary approach
Multidisciplinary approach
  • Physiotherapy
  • Occupational Therapy
  • Psychology
  • Pain Management Programmes
other therapies
Other therapies
  • TENS
  • Acupuncture
  • Nerve Blocks
  • Surgical Lesioning
  • Intrathecal Drug Delivery Systems
  • Spinal cord stimulation
  • Motor cortex stimulation
  • Deep brain stimulation
  • repetitive Transcranial Magnetic Stimulation

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