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Neuropathic Pain Sequencing — FRCA Final MCQ

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ModeratePain MedicineNeuropathic Pain SequencingFRCA Final

A 60-year-old woman has chronic post-herpetic neuralgia affecting the T4 dermatome and is being managed in a non-specialist setting. Amitriptyline was discontinued because of anticholinergic adverse effects, and pregabalin was discontinued because of dizziness and weight gain. According to NICE CG173, what should be offered next?

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Correct answer: D — Offer duloxetine or gabapentin, selected with the patient

NICE recommends switching to one of the remaining first-line drugs when initial treatment is ineffective or not tolerated, with further switching after unsuccessful second or third trials. Having stopped amitriptyline and pregabalin, this patient may therefore be offered duloxetine or gabapentin, selected according to adverse-effect profiles, comorbidity and patient preference. Gabapentin is not specifically preferred simply because pregabalin was poorly tolerated; both are gabapentinoids and can cause dizziness and weight gain. NICE does not recommend routine combination therapy: this remains a research question because comparative evidence is insufficient. Morphine and the capsaicin 8% patch should not be initiated for neuropathic pain in non-specialist settings unless advised by a specialist.

Reference: National Institute for Health and Care Excellence. CG173: Neuropathic pain in adults: pharmacological management in non-specialist settings, recommendations 1.1.8–1.1.12. Last updated 2020. https://www.nice.org.uk/guidance/CG173/chapter/recommendations