1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See About this guideline for details.

1.1 List of all recommendations

Key principles of care

1.1.1 When agreeing a treatment plan with the person, take into account their concerns and expectations, and discuss:

  • the severity of the pain, and its impact on lifestyle, daily activities (including sleep disturbance) and participation[1]

  • the underlying cause of the pain and whether this condition has deteriorated

  • why a particular pharmacological treatment is being offered

  • the benefits and possible adverse effects of pharmacological treatments, taking into account any physical or psychological problems, and concurrent medications

  • the importance of dosage titration and the titration process, providing the person with individualised information and advice

  • coping strategies for pain and for possible adverse effects of treatment

  • non-pharmacological treatments, for example, physical and psychological therapies (which may be offered through a rehabilitation service) and surgery (which may be offered through specialist services).

    For more information about involving people in decisions and supporting adherence, see Medicines adherence (NICE clinical guideline 76).

1.1.2 Consider referring the person to a specialist pain service and/or a condition-specific service[2] at any stage, including at initial presentation and at the regular clinical reviews (see recommendation 1.1.6), if:

  • they have severe pain or

  • their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation[1] or

  • their underlying health condition has deteriorated.

1.1.3 Continue existing treatments for people whose neuropathic pain is already effectively managed, taking into account the need for regular clinical reviews (see recommendation 1.1.6).

1.1.4 When introducing a new treatment, take into account any overlap with the old treatments to avoid deterioration in pain control.

1.1.5 After starting or changing a treatment, carry out an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.

1.1.6 Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:

  • pain control

  • impact on lifestyle, daily activities (including sleep disturbance) and participation[1]

  • physical and psychological wellbeing

  • adverse effects

  • continued need for treatment.

1.1.7 When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

Treatment

All neuropathic pain (except trigeminal neuralgia)

1.1.8 Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)[3].

1.1.9 If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

1.1.10 Consider tramadol only if acute rescue therapy is needed (see recommendation 1.1.12 about long-term use).

1.1.11 Consider capsaicin cream[4] for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Treatments that should not be used

1.1.12 Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so:

  • cannabis sativa extract

  • capsaicin patch

  • lacosamide

  • lamotrigine

  • levetiracetam

  • morphine

  • oxcarbazepine

  • topiramate

  • tramadol (this is referring to long-term use; see recommendation 1.1.10 for short-term use)

  • venlafaxine.

Trigeminal neuralgia

1.1.13 Offer carbamazepine as initial treatment for trigeminal neuralgia.

1.1.14 If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.



[1] The World Health Organization ICF (International Classification of Functioning, Disability and Health) (2001) defines participation as 'A person's involvement in a life situation.' It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.

[2] A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.

[3] At the time of publication (November 2013), amitriptyline did not have a UK marketing authorisation for this indication, duloxetine is licensed for diabetic peripheral neuropathic pain only, and gabapentin is licensed for peripheral neuropathic pain only, so use for other conditions would be off-label. In addition, the Lyrica (Pfizer) brand of pregabalin has patent protection until July 2017 for its licensed indication of treatment of peripheral and central neuropathic pain; until such time as this patent expires generic pregabalin products will not be licensed for this indication and their use for this condition would be off-label and may infringe the patent. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[4] At the time of publication (November 2013), capsaicin cream (Axsain) had a UK marketing authorisation for post-herpetic neuralgia and painful diabetic peripheral polyneuropathy, so use for other conditions would be off-label. The SPC states that this should only be used for painful diabetic peripheral polyneuropathy 'under the direct supervision of a hospital consultant who has access to specialist resources'. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

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