Cambridgeshire PCT
The Pharmacological Management of Neuropathic Pain in Non-specialist Settings
(following issue of NICE Clinical Guideline 96)
NB: All drug doses listed in
table at bottom of page
Following a diagnosis of neuropathic pain and
appropriate management of any underlying
conditions
For people with non-diabetic neuropathic pain conditions
For people with painful diabetic neuropathy
First-line treatment
• Consider simple analgesia eg paracetamol. If ineffective;
• Offer oral amitriptyline (or alternative TCA eg imipramine or nortriptyline
if patient cannot tolerate side effects)
First-line treatment
• Consider simple analgesia eg paracetamol. If
ineffective;
• Offer oral amitriptyline (or alternative TCA eg
imipramine or nortriptyline if patient cannot
tolerate side effects)
Satisfactory
Pain Reduction
Continue treatment – consider gradually reducing
dose over time if improvement is sustained
Second line treatment
• If TCA ineffective
- offer trial of gabapentin instead of the
original drug
• If TCA effective but insufficient pain reduction
- consider trial of gabapentin in combination
with the original drug.
Perform:
• Early clinical review (after
starting or changing
treatment)
• Regular clinical reviews
(to assess and monitor
effectiveness of chosen
treatments
Unsatisfactory pain
reduction at
maximum tolerated
dose
• If gabapentin ineffective or not tolerated,
consider switch to pregabalin.
Consider referring the person to a specialist pain
service and/or a condition-specific service at any
stage, including at initial presentation and at clinical
reviews, if;
• They have severe pain or
• Pain significantly limits their daily activities or
• Their underlying health condition has deteriorated
Second line treatment
• If TCA ineffective
- offer trial of gabapentin instead of the original
drug
• If TCA effective but insufficient pain reduction
- consider trial of gabapentin in combination with
the original drug.
• If gabapentin ineffective or not tolerated,
consider switch to pregabalin.
• If amitriptyline (or alternative TCA) ineffective or
side-effects limit dose titration, offer trial of
duloxetine instead of TCA after having tried
gabapentinoid drug.
Satisfactory
Pain Reduction
Continue:
• Early clinical review (after starting or changing treatment)
• Regular clinical reviews
• Continue treatment – consider gradually
reducing dose over time if improvement
is sustained
Unsatisfactory pain
reduction at
maximum tolerated
dose
If pain not managed effectively in non-specialist setting:
• Refer the person to a specialist pain service and/or a condition-specific service.
• While waiting for referral:
consider oral tramadol or low dose short acting morphine (eg Oramorph®) instead of or in combination with second-line treatment
consider topical lidocaine for treatment of localised pain (peripheral pain associated with sensory disturbance) only for people who are
unable to take oral medication because of medical conditions and/or disability
Other treatments
• Other than tramadol or low dose short acting morphine, do not start treatment with opioids (such as MST® or oxycodone) without an assessment by a specialist
pain service or condition-specific service
• Other pharmacological treatments that are started by a specialist pain service or condition-specific service may continue to be prescribed in non-specialist
settings, with a multidisciplinary care plan, local shared care agreements and careful management of adverse effects.
Drug doses
• Start at a low dose, as indicated in the table.
• Titrate upwards to an effective dose or the patient’s maximum tolerated dose (no higher than the
maximum dose listed in the table)
Drug
Starting dose
Maximum Dose
Amitriptyline
10mg /day
75 mg/day
Gabapentin
100mg/day
1800mg (divided doses)
Pregabalin
150 mg/day (a)
600 mg/day
(divided into 2 doses)
(divided into 2 doses)
Duloxetine
30 mg/day (b)
120 mg/day
Tramadol (b)
50-100 mg not more often than
400 mg/day
every 4 hours
a) A lower starting dose may be appropriate for some people
b) As monotherapy. More conservative titration may be required if used as combination therapy.