Neuropathic pain: management guidelines
Four evidence-based consensus guidelines for the pharmacologic treatment of neuropathic pain (NP) have recently been updated:
(1) The International Association for the Study of Pain Neuropathic Pain Special Interest Group (NeuPSIG) guidelines,
(2) The Canadian Pain Society (CPS) guidelines, and
(3) The European Federation of Neurological Societies (EFNS) guidelines
(4) The middle-east region guideline for peripheral neuropathic pain. (Table). All guideline recommend TCAs, gabapentin, and pregabalin as first-line treatment options for patients with neuropathic pain (excluding trigeminal neuralgia).
Table. Guidelines for Neuropathic Pain
| Medication Class | NeuPSIG guideline | CPS guideline | EFNS guidelines | MER guideline |
| Tricyclic antidepressants | First line | First line | First line for PPN, PHN, and CP | First line |
| Calcium channel α2-δ ligands (gabapentin and pregabalin) |
First line | First line | First line for PPN, PHN, and CP | First line |
| SNRIs (duloxetine and venlafaxine) | First line | Second line | Second line for PPN | Second line |
| Topical lidocaine | First line for localized peripheral NeP | Second line for localized peripheral NeP | First line for PHN if small area of pain/allodynia | First line for PHN if small area of pain/allodynia |
| Opioid analgesics | Second line except in selected circumstances † |
Third line | Second-third line for PPN, PHN, and CP | Second line |
| Tramadol | Second line except in selected circumstances † |
Third line | Second-third line for PPN and PHN | Second line |
NeuPSIG : Neuropathic Pain Special Interest Group , CPS: Canadian Pain Society, EFNS: European Federation of Neurological Societies, PPN: painful polyneuropathy, PHN: postherpetic neuralgia, CP: central pain, SNRIs: serotonin and norepinephrine reuptake inhibitors, NP:neuropathic pain. *Only medications considered first or second line in 1 of the guidelines are presented. †Opioid analgesics and tramadol were considered first-line options in the following circumstances: for the treatment of acute NP, episodic exacerbations of severe NP, neuropathic cancer pain, and during titration of a first-line medication in patients with substantial pain. MER: Middle East region treatment guidelines for peripheral neuropathic pain
These guidelines recommend TCAs, gabapentin, and pregabalin as first-line treatment options for patients with neuropathic pain (excluding trigeminal neuralgia). They also recommend reserving opioid analgesics and tramadol as second or third line options in most cases, despite the evidence of their efficacy for neuropathic pain.11
The EFNS guidelines emphasize the importance of evaluating the broader effect of pharmacological treatment on overall functional and quality of life measures in patients with NP. Based on these criteria, α2δ-ligand drugs have more data supporting improvement in quality of life in NP patients than TCAs, duloxetine or opioids analgesics.7
References
- Cruccu G, Truini A. A review of neuropathic pain: from guidelines to clinical practice. Pain Ther. 2017 Dec;6(S1):3542.