Neuropathic non-malignant pain

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate to others involved in the care of the patient.

NHS Highland Non Malignant Neuropathic Pain Guidance for Primary Care

Neuropathic pain

Defined as ‘Pain initiated or caused by a primary lesion or dysfunction of the nervous system’

Signs and symptoms

  • Burning
  • Electric shocks
  • Numbness
  • Tingling
  • Shooting/stabbing

Neuropathic pain assessment tools are available to aid diagnosis e.g. LANSS (via Intranet link to chronic pain service). 

Consider possibility of serious underlying pathology and refer for investigation as indicated.

Examples of Neuropathic pain

  • Post Herpetic neuralgia (PHN)
  • Peripheral neuropathy (e.g. diabetic, viral, alcohol, drug/chemotherapy related)
  • Trigeminal neuralgia
  • Nerve root pain
  • Post surgical
  • Phantom limb pain

In General

  • It is important to establish a diagnosis and explain implications and chronicity to the patient and the importance of compliance with treatment.
  • Effective treatment is considered as 30% reduction in pain score and/or improved function.
  • Discuss benefits and possible adverse effect of pharmacological treatments including the importance of titration and review.
  • Distinguish analgesic from antidepressant or anti epileptic drug activity.
  • Simple analgesics and non steroidal anti-inflammatory drugs (NSAIDS) are usually ineffective.
  • Start low and go slow.
  • Explain that side effects may improve with time.
  • Allow 8 weeks of maximum tolerated dose before effects judged and medication stopped.
  • If one drug is ineffective it should be stopped and an alternative option commenced. If however one drug is partially effective consider adding a second drug rather than substituting.
  • Medicines can be discontinued immediately if the patient is still having their medication titrated up and a significant side effect occurs.
  • Patients should be weaned off medication gradually when discontinuing.
  • Carry out regular assessment of effectiveness of treatment during titration period – including assessment of pain control, impact on lifestyle, daily activities and participation, physical and psychological well being ; adverse effects; continued need for treatment.
  • There is increased awareness of the abuse potential of anti neuropathic medications and caution and increased supervision should be exercised when initiating in someone with addiction behaviours.
  • Encourage self Management and provide education.
  • Discuss coping strategies for flare ups.
  • Patient may require further support from a chronic pain management specialist.
Step 1

For localised pain - capsaicin 0.025%, 0.075% cream or levomenthol (menthol) 1% in aqueous cream

Capsaicin cream or levomenthol cream can be used for people with localised neuropathic cream). pain who wish to avoid or cannot tolerate oral treatments. (unlicensed use of levomenthol

  • Advise the patient on the importance of hand washing and cross contamination i.e. avoid lips, eyes.
  • If no response after 4 weeks of treatment – STOP.

For trigeminal neuralgia only - carbamazepine orally

  • Initial dose of 100 to 200mg daily, increasing slowly in increments of 100 to 200mg at weekly intervals.
  • Usual maintenance dose range 600 to 1200mg/day.
  • Maximum dose of 1600mg/day.
  • Monitor liver function.
  • If no response after 8 weeks on maximum tolerated dose reduce down by 100mg at weekly intervals till STOPPED.
Step 2 - Amitriptyline (or nortriptyline)

Amitriptyline is 1st choice. Nortriptyline is useful for patients who cannot tolerate the sedative side-effects of amitriptyline or 1st choice for elderly or frail patients. Both drugs have the same dose and titration schedules. Neuropathic pain is an unlicensed although well established indication for these 2 drugs.

  • Take at night (two hours before sleep) to minimize drowsiness the following day, preferably before 20.00hrs.
  • Start with amitriptyline or nortriptyline 10mg once a day and increase by 10mg every 7 days until a maximum of 75mg per day is established.
  • Frail or elderly patients may require a longer dosing interval i.e. increase every 2 weeks.
  • If no response after 8 weeks on maximum tolerated dose, reduce down by 10mg at weekly intervals till STOPPED.
Step 3 - Gabapentin
  • In adults start at 300mg at night and increase in 300mg increments at weekly intervals aiming for a dose of 900mg 3 times per day. If effective and additional pain relief is required this can be increased up to 1200mg 3 times per day.
  • Lower maximum dose ranges and slower titration will need to be considered in patients with reduced renal function. Please refer to the BNF.
  • In frail or elderly start with 100mg at night and increase by same amount weekly to 600mg 3 times a day. Maximum dose -900mg 3 times a day.
  • If no response after 8 weeks on maximum tolerated dose reduce down by 300mg weekly till STOPPED. Lower maximum dose ranges and slower titration will need to be considered in patients with reduced renal function. Please refer to the BNF.
  • In frail or elderly start with 100mg at night and increase by same amount weekly to 600mg 3 times a day. Maximum dose -900mg 3 times a day.
  • If no response after 8 weeks on maximum tolerated dose reduce down by 300mg weekly till STOPPED.
Step 4 - Duloxetine

This has been accepted by the SMC for treatment of painful diabetic neuropathy.

  • Start with 30mg once a day for two weeks and titrate up to a maximum of 120mg per day in two divided doses if required.
  • If frail or elderly start 20mg once a day and increase by 20mg every two weeks till maximum 60mg per day is established.
  • If no response after 8 weeks on maximum tolerated dose reduce down by 30mg every 2 weeks till STOPPED.
Step 5 – Pregabalin

The evidence is limited but it suggests that if patients have tried gabapentin at 900mg 3 times a day with no benefit it is unlikely they are going to respond to pregabalin. Pregabalin should be used in patients who have developed side-effects that prevented them reaching therapeutic doses of gabapentin.

  • In adults, start at 50 to 75mg at night and increase by 50 to 75mg weekly increments till 300mg twice daily is established.
  • In the frail or elderly patient start 25mg at night and increase by 25mg weekly increments till 150mg twice daily is established.
  • Lower maximum dose ranges and slower titration will need to be considered in patients with reduced renal function. Please refer to the BNF.
  • If no response after 8 weeks on maximum tolerated dose reduce down by pregabalin 50mg to 75mg weekly till STOPPED.

If you require additional advice please contact Chronic Pain Management Service via email for advice on pregabalin use before prescribing (nhshighland.chronicpainadvice@nhs.net)

Step 6 – Tramadol

Follow North NHS Highland Opioid Guidance for Non Malignant Chronic Pain.

Step 7 – Consider referral to the Chronic Pain Management Service
  • Consider referral to Chronic Pain Management Services if the person has severe pain unresponsive to the above measures.
  • The patient’s pain significantly limits their lifestyle, daily activities (including sleep disturbances and participation).

Consider referral to other specialties in line with chronic pain referral pathway i.e. neurology, mental health. 

References and resources

SIGN136 – Management of Chronic Pain

Great Glasgow Chronic Pain Management Guidelines – Neuropathic Guidelines March 2015

NHS Highland Opioid Guidance for Non Malignant Chronic Pain