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Neuropathic Pain - Clinical Guideline, v4 Author: Dr Natarajan Approved by Medicines Clinical Guidance Team Feb 2017 Published 15/03/17 Review by: Feb 2020 of 12

Clinical Guideline Neuropathic pain

(Pain due to nerve damage) Pain can be nociceptive, neuropathic or mixed. The neuropathic component of pain generally responds poorly to conventional analgesics. Consider a neuropathic element to the pain if this occurs. For key words in the history see FEATURES. The accompanying questionnaire can help make a neuropathic component more or less likely, but does not replace your clinical acumen.

FEATURES

CAUSES

• Pain on gentle stimulation (allodynia) • Burning/Stabbing/Tingling/ Numbness • Shooting/Crawling/Pins & Needles • Radiation of Pain See Pain scoring Questionnaires (In appendices 1, 2 and 3) Use appendices1 and 2 for baseline and follow up assessments. Use appendices 3 and 4 for follow up assessments.

• Metabolic: - Diabetes / Alcohol / Chemical / Drugs

• Viral - Post-herpetic/AIDS

• Trauma - Injury/Surgery

• Compression - Sciatica /Brachalgia

• Idiopathic • Malignancy

Try to establish a diagnosis. Serious underlying disease may have to be excluded. Possible investigations include FBC/ U+E/ LFT/ TFT/ BS /B12/ Folate/ ESR/ CRP/ X-rays/ Scans. Routine or urgent referral may be required.

• Success of treatment is in the 40-60% range • Anxiety/depression and sleep disturbance can be significant • Counselling/explanation will be an essential part of treatment

All treatments have potential side-effects (sedation/dry mouth/constipation/ ´hangover`). If no contraindications, build up dose slowly allowing several days before changes - side-effects tend to lessen and the drug is better tolerated. Most patients will suffer side-effects;; it is a balance between analgesia and side-effects.

• Review patients regularly for response to treatment • Warn patients they may get side effects • If drugs are not effective discontinue them and move to next step • Continue to check patient’s diagnosis and neurological status • If management is still a problem refer to PAIN RELIEF CLINIC

Neuropathic Pain - Clinical Guideline, v4 Author: Dr Peter Williams Approved by Medicines Clinical Guidance Team Feb 2017 Review by: Feb 2020 of 12

Treatment Algorithm – Primary & Secondary Care

Step 1

Encourage conventional analgesics as first step (non opioid, NSAID or mild to moderateopioid as per WHO ladder) - usually only partially effective. For poor response add in adjuvant analgesia.

Perform Baseline AssessmentPrescribe:Amitriptyline*If not effective switch to:

Trigeminal NeuralgiaPrescribe:Carbamazepine*

Diabetic patients

Pregabalin* orNortriptyline*

Step 3

Duloxetine*If not effective switch to:

Tramadol should only be considered if acute rescue analgesia is needed (not for long term use)

Step 2

Gabapentin*If not effective switch to:

Neuropathic Pain(Except trigeminal neuralgia)

Refer to secondary care if not effective, not tolerated or contraindicated.

Topical TreatmentConsider capsaicin 0.075% cream* for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatment

*See page 4 for Prescribing Notes

These treatment recommendations take into account NICE Clinical Guideline 173 Neuropathic pain. November 2013 (updated Nov 2014)


Treatment Algorithm – Secondary Care Only

Reassess patientIf adequate trials of morphine or oxycodone have failed, consider tapentadolprolonged release tablets.Only to be initiated or recommended by Chronic Pain Team

Step 4

Reassess patient and add in a strong opiate1st line MorphineOR2nd line Oxycodone (only if morphine is causing intolerable side effects, patient unresponsive to treatment, drug is not effective or if the patient has moderate to severe renal dysfunction CKD 4 or 5).

Step 5

Reassess the patientLidocaine patches 5% reassess response at 2 weeks and discontinue treatmentafter 4 weeks if poor response (NB licensed for Post Herpetic Neuralgia only).

Step 7

Reassess patient and consider capsaicin 8% patch for patients with post herpatic neuralgia, Chronic post surgical, peripheral neuropathy, complex regional pain syndrome, compression neuropathy.

NOTE: To be administered under the supervision of Dr Peter Williams only

Step 6


Prescribing Notes Amitriptyline (unlicensed indication) Start with 10mg once daily at night and increase dose until therapeutic effect reached (max dose 75mg/day) or side effects not tolerated. Trial for 6-8 weeks, with at least 2 weeks at the maximum tolerated dose. If only small dose tolerated add in gabapentin. Gabapentin Start with 300mg three times a day (fast titration) and adjust in 300mg increments every 3 days (maximum 3.6g/day). See BNF for details of dosage schedule in renal impairment and for patients with low body weight, after organ transplantation or over 65 years old. Trial for 3–8 weeks, with at least 2 weeks at the maximum tolerated dose. Duloxetine Start with 60mg once daily. Increase by 60mg after 1 week if necessary (maximum dose 120mg/day). Avoid if eGFR <30ml/min/1.73m3. Trial for 8 weeks at the maximum tolerated dose. See MHRA safety warning for duloxetine;; cases of suicidal ideation and suicidal behaviour. Pregabalin Start with 150mg per day in 2 or 3 divided doses. If necessary, increase to 300mg per day after an interval of 3-7 days, to a maximum of 600mg per day in 2 or 3 divided doses after an additional 7 day interval. See BNF for details of dosage schedule in renal impairment. Trial for 4 weeks at the maximum tolerated dose. Nortriptyline (unlicensed indication) Start with 10 mg once daily. Increase if necessary to 75 mg daily Carbamazepine Start with 100 mg 1–2 times a day, increase gradually according to response;; usual dose 200 mg 3–4 times a day, increased if necessary up to 1.6 g daily Capsaicin 0.075% cream Apply a pea sized amount to the affected area 3 or 4 times a day. For all drugs please refer to the BNF for further information on contraindications, interactions, adverse effects etc.


APPENDIX 1 BRIEF PAIN INVENTORY

(To be used at baseline AND follow up assessments)

Name C/S ______________________________ Date ________________________________ Throughout our lives, most of us have had everyday types of pain from time to time such as minor headaches, sprains and toothache. Have you had pain other than these everyday types of pain during the last week?

YES NO On the diagram, shade in the area[s] where you feel pain. Put an X on the area that hurts the most.

Please rate your pain by circling the one number that best describes your pain at its WORST in the last week.

0 1 2 3 4 5 6 7 8 9 10 No

Pain Pain as bad

as you can imagine

Please rate your pain by circling the one number that best describes your pain at its LEAST in the last week.

0 1 2 3 4 5 6 7 8 9 10 No

Pain Pain as bad

as you can imagine


Please rate your pain by circling the one number that best describes your pain ON AVERAGE.

0 1 2 3 4 5 6 7 8 9 10 No

Pain Pain as bad

as you can imagine

Please rate your pain by circling the one number that best describes your pain RIGHT NOW.

0 1 2 3 4 5 6 7 8 9 10 No

Pain Pain as bad

as you can imagine

Circle the one number that describes how, during the last week, pain has interfered with your - GENERAL ACTIVITY

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere

Completely Interferes

MOOD

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere


WALKING ABILITY

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere


NORMAL WORK [includes both work outside the home and housework]

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere



RELATIONS WITH OTHER PEOPLE 0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere


SLEEP

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere


ENJOYMENT OF LIFE

0 1 2 3 4 5 6 7 8 9 10 Does

Not Interfere


Have you received any treatments for your pain [for example, physiotherapy] or taken any medications on a regular basis for your pain [for example, painkillers] within the last week?

YES NO If you have received any treatments for your pain or taken any medications on a regular basis for your pain within the last week, how much relief, if any, have these treatments or regular medications provided? Please circle the one percentage that most shows how much RELIEF you have received.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No

Relief Complete

Relief


APPENDIX 2

EUROQOL–5D HEALTH QUESTIONNAIRE (To be used for baseline and follow up assessments)

Name ________________________________ C/S ______________________ Date _________ _

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today Mobility I have had no problems in walking about q I have had some problems in walking about q I have been confined to bed q Self-Care I have had no problems with self-care q I have had some problems washing or dressing myself q I have been unable to wash or dress myself q Usual Activities (e.g. work, study, housework, family or leisure activities)

I have had no problems with performing my usual activities q I have had some problems with performing my usual activities q I have been unable to perform my usual activities q Pain/Discomfort I have had no pain or discomfort q I have had moderate pain or discomfort q I have suffered extreme pain or discomfort q Anxiety/Depression I have not been anxious or depressed q I have been moderately anxious or depressed q I have been extremely anxious or depressed q

Please turn page over


To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad

your own health is today, in your opinion. Please do this by

drawing a line at whichever point on the scale indicates how

good or bad your health state is.

Scoring 1-2-3

Pain Clinic Use Only

Mobility

Self-Care

Usual Activities

Pain/Discomfort

Anxiety/Depression

EQ-5D

Health Thermometer

9 0

8 0

7 0

6 0

5 0

4 0

3 0

2 0

1 0

100

Worst imaginable health state

0

Best imaginable health state

Your own health state today


APPENDIX 3

Patient Global Impression Of Change (To be used at follow up assessments in primary & secondary care)

Name C/S ____________________ Date ____________________________________ Since you commenced treatment at Wirral University Teaching Hospital NHS Foundation Trust Chronic Pain Management Clinic, please indicate how your pain condition and quality of life has changed by ticking the appropriate box

Pain Condition and Quality of Life

Very Much Improved

Much Improved

Minimally Improved

No Change

Minimally Worse

Much Worse

Very Much Worse


Thank you APPENDIX 4

Clinician Global Impression Of Change (To be used at follow up assessments in primary & secondary care)

Patient’s Name C/S _____________________ Date ____________________________________ Since the above named patient commenced treatment at Wirral University Teaching Hospital NHS Foundation Trust Chronic Pain Management Clinic, please indicate how you believe that his/her Pain status and Quality of Life has changed by ticking the appropriate box

Pain Condition and Quality of Life

Very Much Improved

Much Improved

Minimally Improved

No Change

Minimally Worse

Much Worse

Very Much Worse


Thank you

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