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There are some concerns around the new NICE guidelines on neuropathic pain.

Revision of the 2010 NICE guidance on the management of neuropathic pain had been widely anticipated following the 2013 draft consultation, which proposed steering prescribers towards less expensive first-line therapies (amitriptyline and gabapentin).

However in the final guidelines, no first-line medicines are recommended and the prescriber has been left to decide between prescribing amitriptyline, duloxetine, gabapentin or pregabalin. NICE says this is because it was unable to recommend an unlicensed medicine (amitriptyline) over similarly evidence-based licensed alternatives – which is pretty much equivalent to asking prescribers to “pick one of the drugs from the BNF”.

No first-line medicines are recommended

 On the plus side:

• It was decided to treat neuropathic pain (NeP) as a ‘blanket condition’ (with the exception of trigeminal neuralgia)
• The requirement for the provision of directed patient information and the lack of recommendation for prescribing strong opioids in NeP in the absence of specialist assessment are both eminently sensible
• The recommendation to seek specialist input at any point is welcome, as pain services can offer non-pharmacological options and other support (e.g. CBT/physiotherapy)
• It is recommended that existing treatments are continued for people whose NeP is already effectively managed. Regular review of the effectiveness and continued need for treatment is suggested, although timescales are not specifically mentioned.

Caution exercised

Drug doses have been removed from the final guidance, so it is worth noting that gabapentinoids may be started more cautiously by specialists than the BNF specifies. Gabapentin is commonly started at a dose of 300mg twice daily (300mg at night on day one) for a week or even more cautiously, and pregabalin may need to be started at doses as low as 25mg twice daily.

As pharmacists, we have a role in supporting patients in titrating up such medicines. One suggestion that may help is to step back to a previous dose (e.g. from gabapentin 300mg twice daily to 300mg at night) if side-effects such as drowsiness or lethargy become problematic, increasing again after a few days or a week.

Another prominent issue is gabapentinoid abuse. Differentiating between patients in genuine distress and those seeking a ‘buzz’ is likely to become even more problematic.

To summarise, while the revision has addressed some of the drawbacks of the older guidance, the broad choice of agents detracts from its potential usefulness.