Neuropathic pain (pain due to nerve damage)

Neuropathic pain (pain due to nerve damage) Clinical Guideline Pain can be nociceptive, neuropathic or mixed. The neuropathic component of pain generally responds poorly to conventional analgesics. Consider a neuropathic element to the pain if this occurs. For key words in the history see FEATURES. The accompanying questionnaire can help make a neuropathic component more or less likely, but does not replace your clinical acumen. FEATURES Pain on gentle stimulation (allodynia) Burning/Stabbing/Tingling/ Numbness Shooting/Crawling/Pins & Needles Radiation of Pain See Pain scoring Questionnaires (In appendices 1, 2 and 3) Use appendices1 and 2 for baseline and follow up assessments. Use appendices 3 and 4 for follow up assessments. CAUSES Metabolic: - Diabetes / Alcohol / Chemical / Drugs Viral - Post-herpetic/AIDS Trauma - Injury/Surgery Compression - Sciatica /Brachalgia Idiopathic Malignancy Try to establish a diagnosis. Serious underlying disease may have to be excluded. Possible investigations include FBC/ U+E/ LFT/ TFT/ BS /B 12 / Folate/ ESR/ CRP/ X-rays/ Scans. Routine or urgent referral may be required. Success of treatment is in the 40-60% range Anxiety/depression and sleep disturbance can be significant Counselling/explanation will be an essential part of treatment All treatments have potential side-effects (sedation/dry mouth/constipation/ hangover`). If no contraindications, build up dose slowly allowing several days before changes - side-effects tend to lessen and the drug is better tolerated. Most patients will suffer side-effects; it is a balance between analgesia and side-effects. Review patients regularly for response to treatment Warn patients they may get side effects If drugs are not effective discontinue them and move to next step Continue to check patient s diagnosis and neurological status If management is still a problem refer to PAIN RELIEF CLINIC Approved by Medicines Clinical Guidelines SubCommittee: Feb 2013 Review by: Feb 2016 Page 1 of 11

Treatment Algorithm Primary & Secondary Care Encourage conventional analgesics as first step (non opioid, NSAID or mild to moderate opioid as per WHO ladder) - usually only partially effective. For poor response add in adjuvant analgesia. Step 1 Non diabetic patients Perform baseline assessment Prescribe: 1. Amitriptyline 10mg at night, increasing to 75mg at night if needed (especially if sleep disturbance) 2. Nortriptyline 10mg at night, increasing to 75mg at night if needed (if amitriptyline is effective but causing intolerable side effects) NB doses greater than 50mg offer limited additional analgesia but markedly increased side effects. Diabetic patients Step 2 Reassess patients after at least 1 month 1. Gabapentin (NB fast titration may be used in patient groups outlined below*) other groups require to be slowly titrated as per BNF. OR 2. Pregabalin 75mg twice daily for 2 weeks. Increasing to 150mg twice daily if inadequate response (use if gabapentin is not effective, or causing side effects). If not effective Duloxetine 60mg once daily. Reassess at 2 months and increase dose to 60mg twice daily If needed. Step 3 Reassess the patient after at least a month and add tramadol if needed. If this is not effective then refer for secondary care opinion. Refer to Treatment Algorithm for Secondary Care overleaf Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 2 of 11

Treatment Algorithm Secondary Care Only Step 4 Reassess the patient Consider capsaicin cream 0.075% regularly three or four times a day. Reassess response at six weeks (NB licensed for post herpetic neuralgia (PHN) and diabetic polyneuropathy only. OR Lidocaine patches 5% reassess response at 2 weeks and discontinue treatment after 4 weeks if poor response (NB licensed for PHN only). Step 5 Reassess patient and consider capsaicin 8% patch for patients with post herpatic neuralgia, Chronic post surgical, peripheral neuropathy, complex regional pain syndrome, compression neuropathy. NOTE: To be administered under the supervision of Dr Peter Williams only Step 6 Reassess patient and add in a strong opiate 1 st line Morphine OR 2 nd line Oxycodone (only if morphine is causing intolerable side effects, patient unresponsive to treatment, drug is not effective or if the patient has moderate to severe renal dysfunction CKD 4 or 5). Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 3 of 11

Prescribing es Amitriptyline versus Nortriptyline Amitryptyline is the most cost effective option of these 2 drugs and is used 1st line. If sleep affected, start with 10mg and increase dose until therapeutic effect reached (see notes above) or side effects not tolerated. If only small dose tolerated add in drug from step 2. Gabapentin/Pregabalin Gabapentin is the most cost effective option of these 2 drugs and is used 1 st line. *Gabapentin fast titration Gabapentin may be initiated in a dose of 300mg three times a day (fast titration) and adjusted in 300mg increments every 3 days if needed in all patients except : 1. Those under 12 or over 65 years old, 2. Those with renal dysfunction, 3. Patients with low body weight, 4. Patients post renal transplant. These groups need titration as per BNF. Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 4 of 11

APPENDIX 1 BRIEF PAIN INVENTORY (To be used at baseline AND follow up assessments) Name C/S Date Throughout our lives, most of us have had everyday types of pain from time to time such as minor headaches, sprains and toothache. Have you had pain other than these everyday types of pain during the last week? YES NO On the diagram, shade in the area[s] where you feel pain. Put an X on the area that hurts the most. Please rate your pain by circling the one number that best describes your pain at its WORST in the last week. No Pain Pain as bad as you can imagine Please rate your pain by circling the one number that best describes your pain at its LEAST in the last week. No Pain Pain as bad as you can imagine Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 5 of 11

Please rate your pain by circling the one number that best describes your pain ON AVERAGE. No Pain Pain as bad as you can imagine Please rate your pain by circling the one number that best describes your pain RIGHT NOW. No Pain Pain as bad as you can imagine Circle the one number that describes how, during the last week, pain has interfered with your - GENERAL ACTIVITY s MOOD s WALKING ABILITY s NORMAL WORK [includes both work outside the home and housework] s Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 6 of 11

RELATIONS WITH OTHER PEOPLE s SLEEP s ENJOYMENT OF LIFE s Have you received any treatments for your pain [for example, physiotherapy] or taken any medications on a regular basis for your pain [for example, painkillers] within the last week? YES NO If you have received any treatments for your pain or taken any medications on a regular basis for your pain within the last week, how much relief, if any, have these treatments or regular medications provided? Please circle the one percentage that most shows how much RELIEF you have received. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No Complete Relief Relief Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 7 of 11

APPENDIX 2 EUROQOL 5D HEALTH QUESTIONNAIRE (To be used for baseline and follow up assessments) Name C/S Date By placing a tick in one box in each group below, please indicate which statements best describe your own health state today Mobility I have had no problems in walking about I have had some problems in walking about I have been confined to bed Self-Care I have had no problems with self-care I have had some problems washing or dressing myself I have been unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have had no problems with performing my usual activities I have had some problems with performing my usual activities I have been unable to perform my usual activities Pain/Discomfort I have had no pain or discomfort I have had moderate pain or discomfort I have suffered extreme pain or discomfort Anxiety/Depression I have not been anxious or depressed I have been moderately anxious or depressed I have been extremely anxious or depressed Please turn page over Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 8 of 11

To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line at whichever point on the scale indicates how good or bad your health state is. Best imaginable health state 100 9 0 8 0 7 0 Your own health state today 6 0 5 0 4 0 Pain Clinic Use Only Mobility Self-Care 3 0 2 0 Usual Activities Pain/Discomfort 1 0 Anxiety/Depression EQ-5D Health Thermometer Scoring 1-2-3 0 Worst imaginable health state Approved by Wirral Drug & Therapeutics Panel: Oct 2013 Review by: Oct 2016 Page 9 of 11

APPENDIX 3 Patient Global Impression Of Change (To be used at follow up assessments in primary & secondary care) Name C/S Date Since you commenced treatment at Wirral University Teaching Hospital NHS Foundation Trust Chronic Pain Management Clinic, please indicate how your pain condition and quality of life has changed by ticking the appropriate box Pain Condition and Quality of Life Very Much Improved Much Improved Minimally Improved No Change Minimally Worse Much Worse Very Much Worse Thank you Approved by Medicines Clinical Guidelines SubCommittee: Feb 2013 Review by: Feb 2016 Page 10 of 11

APPENDIX 4 Clinician Global Impression Of Change (To be used at follow up assessments in primary & secondary care) Patient s Name C/S Date Since the above named patient commenced treatment at Wirral University Teaching Hospital NHS Foundation Trust Chronic Pain Management Clinic, please indicate how you believe that his/her Pain status and Quality of Life has changed by ticking the appropriate box Pain Condition and Quality of Life Very Much Improved Much Improved Minimally Improved No Change Minimally Worse Much Worse Very Much Worse Thank you Approved by Medicines Clinical Guidelines SubCommittee: Feb 2013 Review by: Feb 2016 Page 11 of 11