WIREDGOV

Today (24 March) the National Institute for Health and Clinical Excellence (NICE) has outlined the most effective drugs that healthcare professionals in general and community settings should prescribe adults with neuropathic pain, a potentially debilitating condition that affects thousands in the UK. This is the first time that a clinical guideline has been published in this area.

It has been estimated that approximately 1-2% of adults in the UK suffer from pain with neuropathic features. It is associated with a number of conditions - such as diabetes, HIV, cancer, shingles, multiple sclerosis, and stroke - and is caused by damage or changes to nerves, including after limb amputation and other surgical operations.

Typically common painkillers such as aspirin, ibuprofen and paracetamol are ineffective at treating this, but there are other drugs available on the NHS that can help. NICE’s new clinical guideline outlines which drugs should be prescribed in non-specialist settings and in what order these treatments should be given.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: “Neuropathic pain commonly occurs alongside a vast number of chronic health problems. It can be difficult to treat because it is resistant to certain medications and some of those that do work can have unpleasant side effects for the people that take them.

“Our clinical guideline hopes to standardise the pharmacological care pathways for treating neuropathic pain in general and community healthcare settings. Around 95% of all patients with neuropathic pain are currently given medication to manage their pain, so it is important that health professionals are supported in providing the right treatments. This is the first time that we have published a clinical guideline in this area and so we hope it will be of great use to health professionals in these settings.”

Among the recommendations, NICE advises that:

• Healthcare professionals should prescribe amitriptyline (an antidepressant) or pregabalin (an anticonvulsant) as a first line treatment, or oral duloxetine (another antidepressant) if they have painful diabetic neuropathy.
• As a second line treatment, if patients continue to suffer from neuropathic pain at the maximum tolerated dose, health professionals should prescribe a drug from another therapeutic class (for example, amitriptyline if they have already been prescribed pregabalin, or vice versa). This should be taken either by itself or in combination with the original drug.
• If patients continue to suffer from their neuropathic pain, health professionals should then refer them to a specialist-pain and/or condition-specific service for further treatment. While they are waiting for this referral, non-specialist health professionals can prescribe oral tramadol (an analgesic) alongside the ongoing second-line treatment, or topical lidocaine (an anaesthetic) if they have localised pain and are unable to take medication orally.
• Health professionals in non-specialist settings should only prescribe opioids (such as morphine or oxycodone) for their neuropathic pain if the patients have been assessed by a specialist pain or condition-specific service beforehand.
• Healthcare professionals in non-specialist settings can still prescribe pharmacological treatments not recommended in the clinical guideline, providing that they are started by a specialist pain or condition-specific service.

Dr Peter Barry, Chair of the Guideline Development Group that produced the recommendations for NICE and a Consultant in Paediatric Intensive Caresaid:

“Prior to this clinical guideline, there was no nationally-agreed treatment plan for the pharmacological management of neuropathic pain in non-specialist settings. This has meant that prescribing habits have varied across the NHS; clinicians will not have definitively known in which order effective drugs should be prescribed, how long for and in what dosages. There was also ambiguity over when to refer these patients on for specialist interventions.

“In developing this guideline, we have worked with a variety of experienced professionals to ensure that our recommendations are robust, based on the most up-to-date evidence and of the greatest benefit to the patients that have this potentially debilitating condition. We hope that healthcare professionals in these settings, and patients alike, will feel empowered by this.”

Ms Heather Wallace, who has suffered from neuropathic pain for 43 years following surgery, and who was a Patient Representative on the Guideline Group,said:

"Having suffered from neuropathic pain from a very young age, I know how unbearable it can be. At one stage I had to give up work and even simple chores like shopping or cooking were very difficult. It took a while to find the combination of treatments that suited me best and minimised unwanted side effects, but today I am able to enjoy life again.

“Neuropathic pain can be a lifelong condition so it’s very important that the symptoms are identified and treated early on. Hopefully this guideline from NICE will mean that people with this type of pain are given the right drug treatments as soon as possible.”

Professor Blair H Smith, a GP and specialist in primary care medicine and Guideline Developer said:

“Although neuropathic pain is seen by many GPs, treating it effectively can very much be a trial and error process as some drugs can work better than others, and some can result in adverse reactions for the patients that take them.

“Treating neuropathic pain in its own right, rather than as a symptom of multiple other diagnoses, will give GPs a straightforward approach to managing this complex condition.  While it is, of course, important to diagnose and address any curable or dangerous causes of pain, and to minimise any associated co-morbidities, it is timely that NICE has given this complex and distressing condition the appropriate recognition for primary care and other non-specialist settings.”

Dr John Lee, a Consultant in Pain Medicine at the University College London Hospitals and Guideline Developer said:

"Having a framework in place for initiating treatments without the need for specialist advice, will help patients access care more quickly, and will improve the use of available resources."