Pharmacological management of
neuropathic pain
Imran Afzal
ST1 Manorlands
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
What is the estimated prevalence of
neuropathic pain in the UK?
1. 10-15 %
2. 5-10%
3. 1-2%
Evidence: Bowsher et al Pain clinic 1991
telephone survey of 1037 households
NICE Recommendations
What is the first line treatment for
neuropathic pain in diabetic patient?
1. Tramadol
2. Amitryptiline
3. Duloxetine
4. Fentanyl
5. Ibuprofen
NICE Recommendations
Which group of anti depressants duloxetine
belongs to?
1. TCA
2. SSRIs
3. SNRI
4. MAO-I
NICE Recommendation
Which opioid NICE recommends to use
as 3rd line treatment for neuropathic pain?
1. MST
2. Fentanyl
3. Buprenorphine
4. Tramadol
5. Oxycodone

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 RecommendationsKey principles
Consider referring to specialist pain
service if
1. Pain is severe
2. Pain substantially limits daily activities
3. Underlying health condition
deteriorated

NICE RecommendationsKey principles
 Taper or switch treatment slowly
 Early clinical review on changing Rx
 In regular clinical review assess
1. Pain reduction
2. SEs
3. Daily activities
4. Mood
5. Quality of sleep
6. Overall improvement
NICE RecommendationsKey principles
Continue existing treatment if pain
controlled
 Respond to person’s concerns &
expectations
 Explain dose titration, give written advice
if possible

NICE RecommendationsKey principles
When selecting a drug consider
1. Person’s vulnerability including age, comorbidity to SEs
2. Safety considerations and CIs
3. Patient’s preference
4. Lifestyle factors e.g., occupation
5. Mental health problems
6. Any other medication being taken

NICE Guidelines
FIRST LINE TREATMENT
 Except for painful diabetic neuropathy
offer oral amitrptyline or pregabalin
1. Amitriptyline: start at 10mg, gradually
increase, max 75 mg/day
2. Pregabalin: start at 150 mg/ day in 2
doses, gradually increase, max 600mg/d
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
NICE Guidelines
SECOND LINE TREATMENT
If pain reduction unsatisfactory and
1. Rx was amitryptiline , switch to/
combine pregabalin
2. Rx was pregabalin, switch to/combine
amitryptiline
3. RX was duloxetine, switch to
amitryptiline or pregabalin single or
combined
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
NICE GuidelinesOvercoming 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

Questions?
 Thank you!
