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!