Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain, including painful peripheral neuropathy, in adults (except trigeminal neuralgia) NICE CG173.
If the initial treatment is not effective or not tolerated, offer one of the remaining three drugs and consider switching if necessary, until a suitable treatment is found or all options are tried NICE CG173.
Regular clinical reviews should be carried out to assess pain control, impact on lifestyle, adverse effects, and ongoing need for treatment NICE CG173.
For localized neuropathic pain, capsaicin cream may be considered if oral treatments are not tolerated or ineffective NICE CG173.
Do not start certain treatments such as cannabis sativa extract, capsaicin patch, lacosamide, lamotrigine, levetiracetam, morphine, oxcarbazepine, topiramate, venlafaxine, or sodium valproate in primary care unless advised by a specialist NICE CG173.
Referral to specialist pain services or condition-specific services should be considered if pain is severe, significantly limits activities, or underlying health deteriorates NICE CG173.
Key References
- CG173 - Neuropathic pain in adults: pharmacological management in non-specialist settings
- CKS - Neuropathic pain - drug treatment
- CKS - Palliative cancer care - pain
- NG193 - Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain
- CG147 - Peripheral arterial disease: diagnosis and management