NEUROPATHIC PAIN

Question 1

According to SIGN guideline, what is initial treatment for neuropathic pain?

Answer 1

amitriptyline start 10mg titrate to 25mg - 125mg

gabapentin start 300mg and increase by 300mg per week until effective. Min 1.2g daily but may need to be as high as 3.6g

Question 2

If 1st line treatment not effective or tolerated what could be tried next?

Answer 2

pregabalin start 75mg up to max 300mg bd

Question 3

Step 3. Alternative agents?

Answer 3

alternative TCAs - imipramine, nortriptyline

SNRI - duloxetine may be used 60mg up to 120mg

Although many anti-epilepsy drugs have been used in the treatment of neuropathic pain, apart
from carbamazepine, there is little evidence to support their use. Carbamazepine should be used as
a first line agent in patients with trigeminal neuralgia

Question 4

Localised neuropathic pain - step 4

Answer 4

may be appropriate to use lidocaine patch up to 3 at a time

Question 5

Step 5

Answer 5

opioids. no higher than 180mg morphine in a day.

Long acting, avoid breakthrough dosing

Question 6

When should referral to pain clinic happen?

Answer 6

To specialist pain service if:
{ there is treatment failure after trial of four drugs for neuropathic pain
{ the opioid dose is greater than 180 mg morphine per day or equivalent
{ there is an inadequate response to non-specialist management.