What are the recommended first-line treatment options for managing CRPS in primary care?

In primary care, the recommended first-line treatment options for managing complex regional pain syndrome (CRPS), classified as a type of chronic primary pain, focus primarily on non-pharmacological approaches and cautious use of pharmacological treatments.

Pharmacological treatment: Antidepressants such as amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline may be considered to help with pain, sleep, psychological distress, and quality of life, after a full discussion of benefits and harms with the patient. This use is off-label but supported by NICE guidance for chronic primary pain including CRPS.

Medications not recommended: NICE advises against initiating antiepileptic drugs including gabapentinoids (e.g., gabapentin, pregabalin), opioids, non-steroidal anti-inflammatory drugs, paracetamol, benzodiazepines, antipsychotics, corticosteroid injections, ketamine, and local anaesthetics for CRPS in primary care outside clinical trials.

Non-pharmacological management: Emphasis is placed on physical and psychological therapies, often delivered through rehabilitation services, and referral to specialist pain or condition-specific services if pain is severe or significantly impacts daily activities.

Therefore, first-line management in primary care involves careful use of antidepressants alongside non-pharmacological therapies, with avoidance of other pharmacological agents unless under specialist advice or clinical trial settings.

Referral to specialist pain services should be considered early if pain is severe or disabling.

Summary: Offer antidepressants (e.g., amitriptyline) and non-pharmacological therapies; avoid gabapentinoids and opioids; consider specialist referral as needed.

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