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
diagram_neuro_pain.jpg

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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