An Approach to Neuropathic Pain

• Patients with neuropathic pain should have a trial of a tricyclic antidepressant and/or an anticonvulsant (Evidence Grade A, Level 1a and 1b)
• The effectiveness of opioids (especially methadone) must not be forgotten when treating neuropathic pain
• Combination therapy with two or more drugs should be considered in the event of partial response to a single medication
• Other options such as NMDA receptor antagonists (e.g. ketamine) and antiarrhythmic agents (e.g. lidocaine) are not routinely used as first-line but are sometimes tried by clinicians with experience/skill in the use of these agents
• An analgesic ladder for neuropathic pain such as that below has been suggested as an approach to neuropathic pain

Adapted with permission from Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006. p. 264.

SOURCES/REFERENCES

1. Galvez R, Ruiz S, Romero J. A different analgesic ladder for neuropathic pain? Eur J Pain 2007;11(1 Suppl):79. [Online]. Available from: URL:http://www.europeanjournalpain.com/issues/contents?issue_key=S1090-3801(07)X0062-4
2. Harden N, Cohen M. Unmet needs in the management of neuropathic pain. J Pain Symptom Manage 2003;25(5 Suppl):S12-17. http://www.ncbi.nlm.nih.gov/pubmed/12694988
3. McQuay H, Tramer M, Nye B, Carroll D, Wiffen P, Moore R. A systematic review of antidepressants in neuropathic pain. Pain 1996;68(2-3):217-227. http://www.ncbi.nlm.nih.gov/pubmed/9121808
4. Scottish Intercollegiate Guidelines Network. Guideline no. 106. Control of pain in adults with cancer. [Online] 2000. Available from: URL:http://www.sign.ac.uk/guidelines/fulltext/106/index.html
5. Sindrup S, Jensen T. Pharmacotherapy of trigeminal neuralgia. Clin J Pain 2002;18(1):22-27. http://www.ncbi.nlm.nih.gov/pubmed/11803299

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