Need for CHANGE in the treatment of Neuropathic Pain?
The first step in the management of neuropathic pain/localized neuropathic pain is a correct diagnosis which is often time consuming and difficult.
Consensus treatment guidelines for the pharmacological management of pain developed by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) and by the European Federation of Neurological Societies (EFNS) Task Force have been updated.1, 2
There was consensus that first-line treatment should be a topical analgesic agent, because the benefit/risk ratios are far better than for systemic agents. Topical application offers site-specific delivery, a lower total systemic dose and avoidance of first-pass metabolism, reducing the risk of adverse events and drug/drug interactions.3
The NeuPSIG proposes a stepwise management of neuropathic pain.1
The first step includes pain assessment and diagnosis. In this phase, the likely cause and treatment of neuropathic pain, as well as relevant comorbidities influencing NP treatment, are established. Good physician patient communication is crucial in this phase to establish realistic goals and to explain the nature of any treatment.
In the next step, therapy is initiated for any underlying disease-causing neuropathic pain. In addition, one of the first-line medications for symptom management of NP is given. In parallel with this, the physician will undertake a patient evaluation for any non-pharmacological treatment.
In the following step, pain and health-related quality of life (HR-QoL) are re-assessed to facilitate any further decision-making regarding pain relief.
In this recurring step, the choice is made to continue treatment if the patient experiences substantial pain relief, add an alternative first-line medication to therapy if the patient experiences only partial relief, or switch to an alternative first-line medication if there is no, or inadequate, pain relief.
When a switch to an alternative first-line medication is not possible, treatment should proceed to step 4, which involves choosing a second-, third-, or fourth-line medication as an alternative.
In some special cases, second-line medication should be added to first-line medication, for instance, in cases of severe acute NP, or NP due to cancer.
1 Dworkin RH, et al. Impact of postherpetic neuralgia and painful diabetic peripheral neuropathy on health care costs. J Pain. 2010; 11:360-8.
2 Attal N et al. Eur J Neurol. 2010;17:1113-e88.
3 Allegri M et al. A pharmacological treatment algorithm for localized neuropathic pain. Curr Med Res Opin 2016; 32:377-384.