A Treatment Guideline for Neuropathic Pain

Kook Jin Chung; Jae Hyup Lee; Changju Hwang; Myun Whan Ahn

doi:10.4184/jkss.2011.18.4.246

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Chung, Lee, Hwang, and Ahn: A Treatment Guideline for Neuropathic Pain

Original Article

Journal of Korean Spine Surg 2011;18(4):246-253.

Published online: 21 December 2011

DOI: https://doi.org/10.4184/jkss.2011.18.4.246

A Treatment Guideline for Neuropathic Pain

Kook Jin Chung, M.D., Jae Hyup Lee, M.D.^∗,, Changju Hwang, M.D.^†, Myun Whan Ahn, M.D.

Department of Orthopaedic Surgery, College of Medicine, Hallym University, Seoul, Korea

^∗Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Korea

^†Department of Orthopaedic Surgery, College of Medicine, Ulsan University, Seoul, Korea

^‡Department of Orthopaedic Surgery, College of Medicine, Yeungnam University, Daegu, Korea

Corresponding author: Jae Hyup Lee, M.D. Department of Orthopaedic Surgery, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 39, Boramae-Gil, Dongjak-Gu, TEL: 82-2-870-2314, FAX: 82-2-870-3863 E-mail: spinelee@snu.ac.kr

Received 12 August 2010 Revised 25 July 2011 Accepted 2 August 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

A review of literature including definition, diagnosis and treatment of neuropathic pain.

Objectives

To review and discuss the treatment guideline for neuropathic pain.

Summary of Literature Review

Neuropathic pains are characterized by partial or complete somatosensory change caused by various disorders affecting central and peripheral nervous system, and are especially problematic because of their severity, chronicity and resistance to simple analgesics.

Materials and Methods

Review of literature.

Results

Tricyclic antidepressants and the anticonvulsants gabapentin and pregablin were recommended as first-line treatments for neuropathic pain. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in selected clinical circumstances. Other medications such as dual reuptake inhibitors of both serotonin and norepinephrine would be used in severe cases. More invasive interventions (e.g., spinal cord stimulation) may sometimes be helpful.

Conclusions

Treatment must be individualized for each patient and aggressive, combinatory pharmacotherapy and multidisciplinary approach are recommended for the treatment of neuropathic pain.

Keywords: Neuropathic pain, Definition, Diagnosis, Treatment guideline

REFERENCES

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Figures and Tables%

Fig. 1.

This algorithm shows the management of neuropathic pain in primary care. Topical antineuralgics such as lidocaine patch is useful for focal neuropathy such as postherpetic neuralgia.

Table 1.

Classification of neuropathic pain by anatomical location and etiology.

Peripheral	Central
Complex regional pain syndrome	Cervical or thoracic myelopathy
Neural entrapment syndrome	Spinal cord injury
Cervical, thoracic and lumbar radiculopathy	Syringomyelia
Neural compression by tumor	Spinal cord compression (e.g. cancer)
Diabetic neuropathy

Table 2.

Grading system for neuropathic pain.⁹⁾

Criteria to be evaluated for each patient
1. Pain with a distinct neuroanatomically plausible distribution
2. A history suggestive of a relevant lesion or disease affecting the peripheral or central somatosensory system
3. Demonstration of the distinct neuroanatomically plausible distribution by at least one confirmatory test
4. Demonstration of the relevant lesion or disease by at least one confirmatory test

Grading of certainty for the presence of neuropathic pain:

Definite neuropathic pain: all (1 to 4)

Probable neuropathic pain: 1 and 2, plus either 3 or 4

Possible neuropathic pain: 1 and 2, without confirmatory evidence from 3 or 4.

Table 3.

Neuropathic pain medications.

Drug	Starting dose	Titration	Usual maintenance dose (and maximum)	Adverse effects	Duration of adequate trial	Comments
Tricyclic antidepressants
amitriptyline Imipraine Nortriptyline desipramine	10-25 mg/day	increase weekly by 10 mg/day	50-150 mg/day	Drowsiness, confusion, orthostatic hypotension, dry mouth, constipation, urinary retention, weight gain, arrthythmia	6-8 weeks with at least 1-2 week at maximum tolerated dosage	Amitriptyline more likely to produce drowsiness and anticholinergic side effects; contraindicated in patients with glaucoma, symptomatic prostatism and significannt cardiovascular disease
Calcium channel α₂-δ ligand
Gabapentin	100-300 mg at bedtime or 100-300 mg three times daily	Increase by 100-300 mg three times daily every 1-7 days as tolerated	300-1200 mg three times daily	Drowsiness, dizziness, peripheral edema, visual blurring	3-8 weeks for titration plus 2 weeks at maximum dosage	Dosage adjustments required in renal failure
Pregabalin	50 mg tid or 75 mg bid	Increase to 300 mg daily after 3-7 days, then by 150 mg/d every 3-7 days as tolerated	150-300 mg twice daily	Drowsinee, dizziness, peripheral edema, visal blurring	4 weeks	Similar adjustments in renal failure
Topical lidocaine
5% lidocaine patches or gel	Maximum of 3 patches daily for a maximum of 12 h	None needed	Maximum of 3 patches daily for a maximum of 12 -18 h	Local erythema, rash	3 weeks	None
Opioid agonists
Morphine	15 mg every 12 h	After 1-2 wk, convert total daily dosage to long-acting opioid analgesic and continue shortacting medication as needed	30-120 mg every 12 h	Respiratory depression ataxia, nausea, vomiting, sedation, dizziness, urinary retention, constipation	4-6 weeks	History of substance abuse, suicide risk, driving impairment during treatment initiation, constipation requires concurrent bowel regimen
Oxycodone	10 mg every 12 h	After 1-2 wk, convert total daily dosage to long-acting opioid analgesic and continue shortacting medication as needed	20-60 mg every 12 h	Respiratory depression ataxia, nausea, vomiting, sedation, dizziness, urinary retention, constipation	4-6 weeks	History of substance abuse, suicide risk, driving impairment during treatment initiation, constipation requires concurrent bowel regimen
Fentanyl	12-25ug/h patch	After 1-2 wk, convert total daily dosage to long-acting opioid analgesic and continue shortacting medication as needed	25-100 ug/h patch	Respiratory depression ataxia, nausea, vomiting, sedation, dizziness, urinary retention, constipation	4-6 weeks	History of substance abuse, suicide risk, driving impairment during treatment initiation, constipation requires concurrent bowel regimen
Tramadol	50mg once or twice daily	Increase by 50-100 mg daily in divided doses every 3-7 days, as tolerated, until pain relief	50-100 mg 2-3_ daily, maximaum 400 mg/d (100 mg 4 times daily); in patients older than 75 y, 300 mg/d in divided doses	Respiratory depression, ataxia, sedation, constipation, seizures, nausea, orthostatic hypotension	4 weeks	May lower seizure threshold, use with caution in epilepsy, history of substance abuse, suicide risk, driving impairment during treatment initiation, concomitant use of SSRI, SSNRI, TCA or acetaminophen, keep maximal dose of acetaminophen at 4 g to avoid hepatic toxicity,
Selective serotonin noradrenaline reuptake inhibitors
Venlafaxine	37.5 mg once or twice daily	Increase weekly by 37.5 mg/day	150-225 mg/day	Nausea, headache, dizziness, drowsiness, hyperhidrosis, hypertension, constipation, worsening depression	4-6 weeks	Use with caution in concomitant use of tramadol, cardiac disease, withdrawal syndrome with abrupt discontinuation
Duloxetine	30 mg once daily	Increase to 60 mg once daily after one week	60-120 mg/day	Sedation, nausea, somnolence, dizziness, constipation, ataxia, drymouth	4 weeks	Use with caution in hepatic dysfunction, renal insufficiency, alcohol abuse, concomitant use of tramadol

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