Neuropathic pain: The pharmacological management of neuropathic pain in adults in non-specialist settings

Neuropathic pain develops as a result of damage to, or dysfunction of, the system that normally signals pain. It may arise from a heterogeneous group of disorders that affect the peripheral and central nervous systems. 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 an unpleasant sensory and emotional experience that can have a significant impact on a person's quality of life.

Neuropathic pain is often difficult to treat, because it is resistant to many medications and/or because of the adverse effects associated with effective medications. A number of drugs are used to manage neuropathic pain, including antidepressants, anti-epileptic (anticonvulsant) drugs, opioids and topical treatments such as capsaicin and lidocaine. Many people require treatment with more than one drug, but the correct choice of drugs, and the optimal sequence for their use, has been unclear.

Clinicians may be guided by a number of published guidelines and algorithms for the management of neuropathic pain, but these are not consistent regarding the choice of drug treatment. This may lead to variation in practice in terms of which therapy is started, how this is done, whether therapeutic doses are achieved and whether the different types of drugs are used in the correct sequence. Furthermore, guidelines on the management of neuropathic pain rarely include considerations of cost effectiveness. An ongoing systematic review of different treatment pathways for neuropathic pain, commissioned by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme and due to report in 2010, was used to inform this guideline where appropriate.

This clinical guideline covers the management of neuropathic pain conditions in adults (aged 18 or over) in primary care and secondary care, excluding specialist pain management clinics. The aim of the guideline is to provide clear recommendations to healthcare professionals in non-specialist settings on the treatment and management of neuropathic pain. This includes recommendations on appropriate and timely referral to specialist pain services and/or condition-specific services. In general, regarding neuropathic pain as a 'blanket condition', irrespective of the underlying cause, is helpful and practical for both non-specialist healthcare professionals and patients. However, condition-specific recommendations and research recommendations have been made where robust evidence on clinical and cost effectiveness exists for specific conditions, or where the evidence is clearly uncertain. The guideline excludes acute pain arising directly (in the first 3 months) from trauma or orthopaedic surgical procedures.

For all drugs, recommendations are based on evidence of clinical and cost effectiveness and reflect whether their use for the management of neuropathic pain is a good use of NHS resources. This guideline should be used in conjunction with clinical judgement and decision-making appropriate for the individual patient.

The guideline will assume that prescribers will use a drug's summary of product characteristics (SPC) and the British National Formulary (BNF) to inform decisions made with individual patients (this includes obtaining information on special warnings, precautions for use, contraindications and adverse effects of pharmacological treatments). However, the Guideline Development Group (GDG) agreed that having clear statements on drug dosage and titration in the actual recommendations is crucial for treatment in non-specialist settings, to emphasise the importance of titration to achieve maximum benefit.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. When recommendations have been made for the use of drugs outside their licensed indications ('off-label' use), these drugs are marked with an asterisk in the recommendations. Licensed indications are listed in table 1.

Table 1 Licensed indications for recommended pharmacological treatments for neuropathic pain (March 2010)