Neuropathic Pain



Background

Common examples include painful diabetic neuropathy, post-herpetic neuralgia and trigeminal neuralgia. People with neuropathic pain may experience altered pain sensation, areas of numbness or burning, and continuous or intermittent evoked or spontaneous pain.

Neuropathic pain is resistant to many medications and because of the adverse effects associated with effective medications. Drugs used in the management of neuropathic pain include antidepressants, anti-epileptic (anticonvulsant) drugs and opioids.

Overall prevalence estimated at 1-2%. Painful neuropathy in 20% diabetics. Post herpetic neuralgia >10%.

Leeds Assessment of neuropathic symptoms and signs
Clinical Yes No
Is pain a strange sensation like tingling or pins & needles 5 0
Does the pain make skin colour change 5 0
Does the pain make skin sensitive to touch 3 0
Does the pain come in bursts (electric shock) 2 0
Does the skin feel temperature has changed 1 0
Allodynia on examination 5 0
Hyperalgesia on examination 3 0
Score > 12 probably neuropathic (<12 unlikley neuropathic)

First line treatment

First line treatment: Oral Amitriptyline or Pregabalin

  • Amitriptyline: start at 10 mg/day; gradually titrate to maximum of 75 mg/day
  • Pregabalin*: start at 150 mg/day (two doses); titrate to maximum of 600 mg/day

First line treatment in diabetic: Oral Duloxetine (oral amitriptyline if Duloxetine contraindicated)

  • Duloxetine: start at 60 mg/day; titrate to effective dose or maximum 120 mg/day

* Pregabalin: Please note the risk of addiction and illedal misuse (Alert July 2016).

Second line treatment

Trial new agent or in combination with a first line drug.

For non-diabetic patients

  • If first-line treatment was with amitriptyline, switch to or combine with oral Pregabalin.
  • If first-line treatment was with Pregabalin*, switch to or combine with oral amitriptyline.

For people with painful diabetic neuropathy:

  • If first-line treatment was with Duloxetine, switch to amitriptyline or Pregabalin, or combine with Pregabalin*
  • If first-line treatment was with amitriptyline, switch to or combine with PregabalinP

* Pregabalin: Please note the risk of addiction and illedal misuse (Alert July 2016).

Third Line Treatment

If satisfactory pain reduction is not achieved with second-line treatment:
Refer the person to a specialist pain service. While awaiting referral:

  • Consider oral Tramadol as third-line treatment instead of or in combination with the second-line treatment.
  • Consider topical Lignocaine for treatment of localised pain for people who are unable to take oral medication because of medical conditions and/or disability.

The combination of Tramadol with amitriptyline, Nortriptyline, Imipramine or Duloxetine is associated with only a low risk of serotonin syndrome (the features of which include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus). Topical Lidocaine is licensed for post-herpetic neuralgia, but not for other neuropathic pain conditions.


Care pathway

Neuropathic Pain management Flow Diagram


Content by Dr Íomhar O' Sullivan 04/09/2010. Contents from NICE publication CG96. Last review Dr ÍOS 3/12/18.