Neuropathic pain

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Capsaicin cream (Drugs for relief of soft-tissue disorders and topical pain relief) is used in post-herpetic neuralgia, carbamazepine (Antiepileptics) in trigeminal neuralgia and pregabalin (Antiepileptics) in neuropathic pain – see note box below.

Note: Fibromyalgia
Many of the principles involved in the management of neuropathic pain are used with fibromyalgia, however medication is not always required: refer to SIGN 136: Management of chronic pain

Note:
• Pregabalin
should be restricted to use for peripheral neuropathic pain in adults who have not responded to or tolerated conventional first and second-line treatments. Discontinue treatment if the patient has not shown sufficient benefit within 8 weeks of reaching the maximally tolerated therapeutic dose. Optimise tablet strength and use twice-daily dosing to minimise cost. Restrict use of the oral solution to those patients who find it difficult to or are unable to swallow tablets. See Antiepileptics for antiepileptic use.
Gabapentin and pregabalin have the potential for misuse and careful review of some patients’ motivation in asking for them is required; refer to SIGN 136 ‘Management of chronic pain’ (www.sign.ac.uk).

 

Important: Supplementary notes

Many of the principles involved in the management of neuropathic pain are used with fibromyalgia, however medication is not always required: refer to SIGN 136: Management of chronic pain.

AMITRIPTYLINE (First Line)

Important: Therapy notes

Important: Formulation and dosage details

Formulation:

Tablets 10mg, 25mg, 50mg

Dosage:

Chronic non-malignant neuropathic pain guidelines and Scottish Palliative Care Guidelines

 

Important: Formulation and dosage details

Formulation:

Oral solution 25mg/5mL, 50mg/5mL off-label

Dosage:

Chronic non-malignant neuropathic pain guidelines and Scottish Palliative Care Guidelines

NORTRIPTYLINE

Important: Therapy notes

Important: Formulation and dosage details

Formulation:

Tablets 10mg, 25mg off-label

Dosage:

Neuropathic pain if amitriptyline is poorly tolerated: Chronic non-malignant neuropathic pain guidelines and Scottish Palliative Care Guidelines.

GABAPENTIN

Important: Therapy notes

The levels of propylene glycol, acesulfame K and saccharin sodium may exceed the recommended WHO daily intake limits if high doses of gabapentin oral solution (Rosemont brand) are given to adolescents or adults with low body-weight (39–50 kg)—consult product literature.

MHRA advice: Pregabalin (Lyrica), gabapentin (Neurontin) and risk of abuse and dependence: new scheduling requirements (April 2019) (www.gov.uk).

MHRA advice: Gabapentin (Neurontin®): risk of severe respiratory depression (October 2017) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Capsules (CD schedule 3) 100mg, 300mg, 400mg

Dosage:

Neuropathic pain: Chronic non-malignant neuropathic pain guidelines and Scottish Palliative Care Guidelines

Important: Formulation and dosage details

Formulation:

Tablets (CD schedule 3) 600mg

Dosage:

Neuropathic pain: Chronic non-malignant neuropathic pain guidelines and Scottish Palliative Care Guidelines

DULOXETINE

Important: Therapy notes

MHRA advice: Duloxetine: marketed as Cymbalta▼ and Yentreve▼ for different disorders (December 2014) (www.gov.uk).

Important: Formulation and dosage details

Formulation:

Capsules 30mg, 60mg

Dosage:

Diabetic peripheral neuropathic pain after failure of simple analgesics and local measures, and where treatment with amitriptyline (uptitrated) and then with gabapentin has been ineffective or unsuitable: 60mg once daily.
If ineffective, some patients may benefit from 60mg twice daily maximum. Discontinue if inadequate response after 2 months; review treatment at least every 3 months. See: NHS Highland Diabetic neuropathy guidance