NICE Publishes Updated Clinical Guidelines on Neuropathic Pain

The National Institute for Health and Care Excellence (NICE) has published updated recommendations on the management of neuropathic pain. Key recommendations are summarised below:

Principles of care

1. When agreeing a treatment plan with the person discuss:

• severity of pain;
• its effect on lifestyle, daily activities, sleep and participation;
• underlying cause;
• benefits and possible adverse effects of pharmacological treatments;
• the importance of dosage titration and the titration process;
• coping strategies for pain and possible adverse effects; and
• non-pharmacological treatment options.

2. Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, if:

• they have severe pain;
• their pain significantly limits their lifestyle, daily activities, sleep and participation; or
• their underlying health condition has deteriorated.

3. Continue existing treatments for people whose neuropathic pain is already effectively managed, with regular reviews.
4. When introducing a new treatment, take into account overlap with the old treatments.
5. After starting or changing a treatment, carry out an early review of dosage titration, tolerability and adverse effects.
6. Carry out regular reviews of:

• pain control;
• effect on lifestyle, daily activities, sleep and participation;
• physical and psychological well-being;
• adverse effects; and
• continued need for treatment.

7. When withdrawing or switching treatment, taper the withdrawal regimen.

Treatment

All neuropathic pain (except trigeminal neuralgia):

• Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment.
• If the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs.
• Consider tramadol only if acute rescue therapy is needed.
• Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.
• Do not start the following in non-specialist settings, unless advised by a specialist to do so:
  • cannabis sativa extract,
  • capsaicin patch,
  • lacosamide,
  • lamotrigine,
  • levetiracetam,
  • morphine,
  • oxcarbazepine,
  • topiramate,
  • long-term tramadol,
  • venlafaxine, and
  • sodium valproate.

Trigeminal neuralgia:

• Offer carbamazepine as initial treatment.
• If carbamazepine is not effective, not tolerated or contraindicated, consider seeking expert advice from a specialist.

The guidance also includes recommendations on future research.

This article originally appeared on Univadis, part of the Medscape Professional Network.