Drug Titration and Review for Patient presents with

Neuropathic Pain neuropathic pain

Link to HMMC guidance: http://

www.enhertsccg.nhs.uk/central-nervous- Agree an achievable pain relief
system goal
(e.g. 50% pain relief or ability to
undertake global activities) and
document on the traffic light assessment
tool sheet/PIL

Advise patient on the

medication, titration regime
(see drug specific information below) and
target dose. Document target dose on
traffic light assessment tool sheet /PIL

Explain traffic light assessment

tool to patient Traffic light assessment Click for
Advise patient to keep increasing the more
tool
dose guided by titration regime, target info
dose & traffic light response

Ask patient to complete

‘Dose achieved’, ‘Response’ and ‘State
side-effects’ sections and bring to their
next review appointment for discussion

Review after 6 weeks

Action using the traffic light assessment
tool

Click for TCAs: Amitriptyline/ Click for Click for Click for Click for Duloxetine
Gabapentin more more Carbamazepine more Pregabalin more Fluoxetine more Start with 30mg/day and
info
Nortriptyline info info info info after 2 weeks increase to
60mg/day

Review at 6 weeks using traffic Click for

more
light tool info

Green light Amber light Red light

Response: Response: Response:
·Adequate pain benefit achieved with ·Marginal pain benefit with tolerable side- · No pain relief and/or intolerable side-effects
tolerable side-effects effects Action:
Action: Action: · Change therapy
·Continue medication at current dose and ·Consider dose achieved and level of pain ·Change therapy in accordance with the
review regularly. relief vs side-effects: recommended drugs in the initial
·Consider gradual dose reduction over time · If not at target dose - titrate to target dose management pathway Neuropathic Pain
if sustained improvement · If target dose achieved - consider changing ·Refer non-responders as per the initial
therapy management pathway Neuropathic Pain
Back to Traffic
Traffic light
light assessment
assessment tool
tool
pathway
Back to
pathway
Back to TCAs:
TCAs: Amitriptyline/
Amitriptyline/ Nortriptyline
Nortriptyline
pathway

·· Age
Age ≤≤ 60
60 -- start
start with
with 25mg
25mg at
at night
night and
and titrate
titrate in
in 25mg
25mg increments
increments every
every 3-4
3-4 days
days
·· Age
Age >> 60
60 -- start
start with
with 10mg
10mg at
at night
night and
and titrate
titrate in
in 10mg
10mg increments
increments every
every week
week
·· IfIf unable
unable to
to tolerate
tolerate 10mg
10mg increments
increments consider
consider using
using liquid
liquid amitriptyline
amitriptyline to
to allow
allow smaller
smaller increments
increments -- this
this isis more
more expensive
expensive than
than gabapentin
gabapentin
·· Maximum
Maximum daily
daily dose
dose of
of TCA
TCA == 75mg
75mg
Back to Carbamazepine
Carbamazepine
pathway

Start
Start at
at 100mg
100mg twice
twice daily
daily and
and titrate
titrate the
the dose
dose gradually
gradually until
until pain
pain isis relieved
relieved (increase
(increase by
by aa maximum
maximum of of 100mg
100mg every
every 33 days).
days). AA dose
dose of
of
200mg
200mg 33 or
or 44 times
times daily
daily isis usually
usually sufficient
sufficient toto maintain
maintain pain
pain free
free state.
state. Maximum
Maximum daily
daily dose
dose == 1600mg
1600mg
Once
Once pain
pain in
in remission
remission gradually
gradually reduce
reduce toto lowest
lowest effective
effective dose.
dose. Once
Once stable
stable optimise
optimise tablet
tablet strength
strength
Back to
pathway
Back to Fluoxetine
Fluoxetine
pathway

Start
Start with
with 20mg/day
20mg/day andand increase
increase gradually
gradually after
after 3-4
3-4 weeks
weeks ifif necessary.
necessary.
Maximum daily dose = 60mg (usually 40mg in the elderly).
Maximum daily dose = 60mg (usually 40mg in the elderly).
Prescribe
Prescribe as
as 20mg
20mg capsules
capsules