DGRefHelp - NHS Dumfries & Galloway
- Neuro-anatomically plausible distribution of pain symptoms and history suggestive of relevant disease or lesion (eg. diabetes and stocking distribution of pain)
- Altered pain sensation (eg allodynia, hyperalgesia)
- Areas of numbness or burning
- Continuous or intermittent evoked or spontaneous pain
- Consider using neuropathic pain assessment tools like LANSS or PAINDETECT
Neuropathic pain management
Warning
Consider the following special situations
Red flags
- Diagnostic uncertainty
- Patient has severe pain
- Pain significantly limits daily activities
- Underlying health condition has deteriorated
Referral to specialist care
- Failure of medical management
- Consideration of Qutenza and other interventions
- Consideration of MDT assessment and management
Chronic regional pain syndrome
- Patient information and education
- Medication and procedures
- Physical and vocational rehabilitation
- Psychological intervention
Do not forget self management resources - Pain Association, Pain Concern and NHS Inform
Choice depends on patient factors and physician preference
Amitriptyline
Start at 10 mg at night time increase at 10 mg increments per week up to dose with maximum benefit and least side effects
- Maximum dose – 125 mg
Gabapentin
Start at 300 mg at night time and build up in 300 mg increments per week (through the day to make it 3 times a day ) up to a dose that gives maximum benefit with least side effects
- Minimum effective dose – 1200mg/day
- Maximum recommended dose – 3600 mg/day
Pregabalin
If amitriptyline or gabapentin is not effective or not tolerated). Start at 75 mg twice a day and build up to a dose with maximum benefit with least side effects.
- Minimum effective dose no less than 150 mg
- Maximum recommended dose – 600mg/day
Alternative Tricyclics
Nortriptyline or Imipramine in doses between 25-75mg/daily
SNRI antidepressants/Cabamazepine
- Duloxetine 60 mg/day up to 120 mg/day
- Carbamazepine – Start at 100-200 mg daily
- increase by 100-200 mg increments biweekly
- maximum of 1600mg/daily in divided doses
Topical agents
- Lidocaine 5% plaster can be used for localised neuropathic pain to be applied for 12 hrs and off for 12 hrs. Maximum dose – 3 patches each time
- Capsaicin 0.075% cream could be used 3-4 times a day for 3-4 weeks
Consider opioids but...
Please remember to wean patient off opioids if not effective.