Neuropathic painImplementing NICE guidance

March 2010

NICE clinical guideline 96

What this presentation covers

Background

Scope

Definitions

Recommendations

Costs and savings

Discussion

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Background

• Neuropathic pain: result of damage to, or dysfunction of the system that normally signals pain

• Examples: trigeminal neuralgia, diabetic neuropathy, post-herpetic pain

• Potential difficulties: resistance to medication, side effects

• Prevalence: estimates vary – different definitions, methods of assessment, patient selection

Scope

Adults with neuropathic pain conditions

Not including

•those who are treated in specialist pain services

or

•first 3 months after trauma or orthopaedic surgery

Definitions

• Non-specialist settings

• Specialist pain services

• Condition-specific services

• Participation

• ‘Off-label’ medicines

Consider referral to a specialist pain service and/or a condition-specific service if: •pain is severe

or•pain significantly limits daily activities and participation

or•underlying health has deteriorated.

Key principles of care: 1

Continue existing treatments for people whose neuropathic pain is already effectively managed

Key principles of care: 2

Address the person’s concerns and expectations about treatment options, including:• benefits and adverse effects• why a particular treatment is chosen• coping strategies• non-pharmacological treatments

Key principles of care: 3

When selecting pharmacological agents consider:

• vulnerability to adverse effects• safety• patient preference• lifestyle• mental health problems• other medication

Key principles of care: 4

• Explain importance of dosage titration and the titration process

• When withdrawing or switching treatment, taper the withdrawal regimen

• When introducing a new treatment, consider overlap with the old treatments

Key principles of care: 5

• Early clinical review after starting or changing treatment

• Regular clinical reviews to assess and monitor treatment effectiveness. Assess:

– pain reduction– adverse effects– daily activities and participation– mood – quality of sleep– overall improvement

Key principles of care: 6

Offer oral amitriptyline* or pregabalin

• Amitriptyline*: start at 10 mg/day; gradually titrate to maximum of 75 mg/day

• Pregabalin: start at 150 mg/day (two doses; consider lower starting dose if appropriate); titrate to maximum of 600 mg/day

First-line treatment

• Offer oral duloxetine: start at 60 mg/day (a lower starting dose may be appropriate for some people); titrate to effective dose or maximum tolerated dose – maximum 120 mg/day

• If duloxetine is contraindicated, offer oral amitriptyline*

First-line treatment:diabetic neuropathy

Early and regular reviews:

•satisfactory improvement – continue the treatment; improvement sustained – consider reducing dose

•first-line amitriptyline* gives satisfactory pain reduction but adverse effects not tolerated – consider oral imipramine* or nortriptyline*

First-line treatment:review

If maximum tolerated dose of first-line treatment doesn’t give satisfactory pain reduction, then after informed discussion:

•offer another drug as an alternative or

•offer another drug in combination with the original

Second-line treatment

If satisfactory pain reduction is not achieved with second-line treatment:

•refer to a specialist pain service and/or a condition-specific service

and

•consider additional or alternative treatment options while waiting for referral

Third-line treatment

• Do not start opioids other than tramadol without specialist assessment

• Medicines started by a specialist service may be continued in a non-specialist setting, subject to agreement and planning

Other treatments

Costs

Because of uncertainty about the prevalence and incidence of neuropathic pain, limited data on current prescribing practice and uncertainty around future practice, it is has not been possible to estimate the national cost of implementation of this guideline.

Discussion

• How do our current prescribing patterns for neuropathic pain compare with the guidance?

• How will our referrals to specialist pain services and condition-specific services change as a result of this guidance?

• What coping strategies do we currently discuss with patients and how should this change?

• How do we record the key elements of clinical review?

NHS Evidence

Find out more

Visit www.nice.org.uk/guidance/CG96 for:

• the guideline

• the quick reference guide

• ‘Understanding NICE guidance’

• costing statement

• audit support