Initial Management of Neuropathic Pain Patient presents with

symptoms suggestive
Link to HMMC guidance: of neuropathic pain
http://www.enhertsccg.nhs.uk/central-nervous-system

Appropriate investigation
and management of any Radicular pain
underlying condition

Trial of conventional
analgesics For suspected radicular pain
Paracetamol / codeine with see Back Pain pathway and
review within 2 weeks assess red flags and manage
accordingly

If codeine ineffective

Click for
Lidocaine plasters more
info
Consider tramadol for
paroxysmal pain and
review within 2 weeks Bordered occlusive Click for
more
dressing info

Click for Review after 1 month and Post Herpetic Neuralgia & Non-
more if still troubled by Post Herpetic Neuralgia
info Localised Neuropathy
symptoms Click for
more
info

Refer non-responders
Peripheral Neuropathy Drug titration and review
to pain specialist
Click for
Click for more
more info
info
Specific management
according to type of Widespread Pain Suggestive of See pathway
neuropathic pain Fibromyalgia Drug Titration and Review
Exclude systemic illness (check TFT, CK, of Neuropathic Pain
inflammatory screen):
Amitriptyline/ nortriptyline

Radicular Pain
Consider referral as per
If red flag symptoms – urgent Drug titration and review
Back Pain pathway
orthopaedic referral Click for
Click for
more
more info
info

Refer non-responders
Trigeminal Neuralgia Drug titration and review
to Neurology
Click for Click for
more more
info info

See pathway
Trigeminal Neuralgia
Back to Review after 1 month and if still troubled by symptoms
pathway

· Use the Pain Detect questionnaire to identify if neuropathic pain likely and type of neuropathic pain.
· Consider using the BPI questionnaire for a baseline global assessment of symptoms (this can be used as a baseline for future audits of response).
· Agree achievable pain goal with patient (e.g. 50% pain relief or ability to undertake global activities) & follow relevant pathway below based on diagnosis.
· For dose titrations, additional information for specific drugs and patient advice refer to titration and review section below.
· Assess treatment efficacy after 6 weeks.
· Use traffic light assessment tool to assess patients’ response to treatment and agree the on-going treatment plan
· Consider depression at all stages, and treat where needed with SSRI.
· Co-prescribing of tramadol, TCAs, duloxetine & SSRIs should be with caution because of the risk of serotonin syndrome
Back to Post Herpetic Neuralgia & Non-Post Herpetic Neuralgia Localised Neuropathy
pathway

· Consider Bordered Occlusive Dressing for localised pain that may respond to a physical barrier
· Amitriptyline/nortirptyline
· off label use - such use is supported by good evidence and/or NICE guidelines. Informed consent should be obtained and documented
· Gabapentin
· if patient is unable to reach maximum dose despite titration (see below) consider pregabalin (pregabalin works on the same pathway as gabapentin
and has the same side effect profile). Informed consent should be obtained and documented for any off label use Lidocaine plasters (see next box)
Back to Lidocaine plasters
pathway

For localised superficial pain and allodynia (pain precipitated by light touch)
· Only licensed for post-herpetic neuralgia - if off label use (supported by good evidence and/or NICE guidelines) informed consent
should be obtained and documented
· Apply to the affected area for 12 hours on and 12 hours off
· Assess pain/sensitive area and how many patches are needed to cover the area. Patches can be cut into smaller sizes.

Maximum of 3 complete patches at the same time

· If effective - review at 6 months and consider trial withdrawal
Back to Bordered occlusive dressing
pathway

Consider a bordered occlusive dressing such as mepilex, for localised pain that may respond to a physical barrier.
· Consider before drug treatment
· To be tried for 1 week to assess benefit
· Ensure adhesive border does not contact painful area
Back to Peripheral Neuropathy
pathway

· Amitriptyline/ nortriptyline
· off label use - such use is supported by good evidence and/or NICE guidelines. Informed consent should be obtained and documented
· Gabapentin
· If patient is unable to reach maximum dose despite titration (see below) consider pregabalin (pregabalin works on the same pathway as gabapentin
and has the same side effect profile). Informed consent should be obtained and documented for any off label use
· In DIABETES, improve glycaemic control
· Consider duloxetine:
· 2nd line in diabetes
· 3rd line in non-diabetics
· off label use - such use is supported by good evidence and/or NICE guidelines. Informed consent should be obtained and documented
Back to Radicular Pain - If red flag symptoms – urgent orthopaedic referral
pathway

Manage/refer all patients as per Back Pain pathway:

· Amitriptyline/ nortriptyline
· off label use - such use is supported by good evidence and/or NICE guidelines. Informed consent should be obtained and
documented
· Gabapentin
· off label use - such use is supported by good evidence and/or NICE guidelines. Informed consent should be obtained and
documented
· If patient is unable to reach maximum dose despite titration consider pregabalin (pregabalin works on the same pathway as
gabapentin and has the same side effect profile). Informed consent should be obtained and documented for any off label use
Back to
pathway Drug
Drug titration
titration and
and review
review

For
For information
information on
on titration
titration of
of Gabapentin,
Gabapentin, Amitriptyline/Nortriptyline,
Amitriptyline/Nortriptyline, Pregabalin,
Pregabalin, Carbamazepine,
Carbamazepine, Fluoxetine
Fluoxetine or
or Duloxetine,
Duloxetine,
see
see Neuropathic
Neuropathic Drug
Drug Titration
Titration pathway
pathway
Back to Trigeminal
Trigeminal Neuralgia
Neuralgia
pathway

··Carbamazepine
Carbamazepine
··Gabapentin
Gabapentin
··IfIf patient
patient isis unable
unable to
to reach
reach maximum
maximum dose
dose despite
despite titration
titration consider
consider pregabalin.
pregabalin. Informed
Informed consent
consent should
should be
be obtained
obtained and
and documented
documented
for
for any
any off
off label
label use
use