Activity 2: Tailoring the Treatment of Neuropathic Pain: Case Studies

Algorithm for the Treatment of Painful Diabetic Neuropathy: Download PDF

Algorithm for the Treatment of Postherpetic Neuralgia: Download PDF

Diagnostic Algorithm for Neuropathic Pain: Download PDF

Recommendation #1: Tricyclic antidepressants or gabapentin/pregabalin are recommended as first-line treatment in postherpetic neuralgia.
Source: Guidelines on pharmacological treatment of neuropathic pain: 2010 revision. European Journal of Neurology 2010;17:1113-23. 
Website: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.02999.x/abstract
Strength of Evidence: A 

Recommendation #2: Topical lidocaine, with its excellent tolerability, may be considered first line in the elderly with postherpetic neuralgia, especially if there are concerns regarding the central nervous system side effects of oral medications.
Source: Guidelines on pharmacological treatment of neuropathic pain: 2010 revision. European Journal of Neurology 2010;17:1113-23. 
Website: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.02999.x/abstract
Strength of Evidence: A

Recommendation #3: Strong opioids and capsaicin cream are recommended as second-line choices for postherpetic neuralgia. Capsaicin patches are promising, but the long-term effects of repeated applications are not clear.
Source: Guidelines on pharmacological treatment of neuropathic pain: 2010 revision. European Journal of Neurology 2010;17:1113-23. 
Website: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.02999.x/abstract
Strength of Evidence: A

Recommendation #4: All patients [with diabetes] should be screened for distal symmetric polyneuropathy at diagnosis and at least annually thereafter using simple clinical tests.
Source: Standards of Medical Care in Diabetes – 2010. Diabetes Care 2010;33(Suppl 1):S11-S61.
Website: http://care.diabetesjournals.org/content/33/Supplement_1/S11.extract
Strength of Evidence: B

Recommendation #5: Electrophysiological testing is rarely needed, except in situations where the clinical features are atypical.
Source: Standards of Medical Care in Diabetes – 2010. Diabetes Care 2010;33(Suppl 1):S11-S61.
Website: http://care.diabetesjournals.org/content/33/Supplement_1/S11.extract
Strength of Evidence: E

Recommendation #6: Tricyclic antidepressants, gabapentin, pregabalin and serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) are recommended as first-line treatment in painful polyneuropathy (notably related to diabetes).
Source: Guidelines on pharmacological treatment of neuropathic pain: 2010 revision. European Journal of Neurology 2010;17:1113-23. 
Website: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2010.02999.x/abstract
Strength of Evidence: A

Recommendation #7: Morphine sulfate, tramadol and oxycodone should be considered for the treatment of painful diabetic neuropathy. 
Source: Evidence-based guideline: treatment of painful diabetic neuropathy. Neurology 2011;76:1758-65.
Website: http://www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.full.pdf+html
Strength of Evidence: B

Recommendation #8: Topical capsaicin should be considered for the treatment of painful diabetic neuropathy.
Source: Evidence-based guideline: treatment of painful diabetic neuropathy. Neurology 2011;76:1758-65.
Website: http://www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.full.pdf+html
Strength of Evidence: B

Recommendation #9: Lidocaine patches may be considered for the treatment of painful diabetic neuropathy.
Source: Evidence-based guideline: treatment of painful diabetic neuropathy. Neurology 2011;76:1758-65.
Website: http://www.neurology.org/content/early/2011/04/08/WNL.0b013e3182166ebe.full.pdf+html
Strength of Evidence: C

Download PDF of EB Recs

American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care 2010;33(Suppl 1):S11-S61.

Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, et al. European Federation of Neurologic Societies guidelines on pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol 2010;17:1113-23.

Bouhassira D, Attal N. Diagnosis and assessment of neuropathic pain: the saga of clinical tools. Pain 2011;152(Suppl 3):S74-S83.

Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114:29-36.

Bril V, England J, Franklin GM, Backonja M, Cohen J, Del Toro D, et al. Evidence-based guideline: treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2011:76;1758-65.

Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009;10:147-59.

Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004;63:959-65.

England JD, Gronseth GS, Franklin G, Carter GT, Kinsella LJ, Cohen JA , et al. Practice parameter: the evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2009;72:177-84.

England JD, Gronseth GS, Franklin G, Carter GT, Kinsella LJ, Cohen JA , et al. Practice parameter: the evaluation of distal symmetric polyneuropathy: the role of laboratory and genetic testing (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2009;72:185-92.

Federation of State Medical Boards of the United States, Inc. Model Policy for the Use of Controlled Substances for the Treatment of Pain. www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf . Accessed September 28, 2011.

Fine P, Portenoy RK. Opioid Analgesia. New York, NY: McGraw Hill; 2004.

Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 2005;352(13):1324-34.

Irving GA, Backonja MM, Dunteman E, Blonsky ER, Vanhove GF, Lu SP, et al. A multicenter, randomized, double-blind, controlled study of NGX-4010, a high-concentration capsaicin patch, for the treatment of postherpetic neuralgia. Pain Med 2011;12:99-109.

Jensen MP, Smith DG, Ehde DM, Robinsin LR. Pain site and the effects of amputation pain: further clarifying the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22.

Jovey RD, Ennis J, Gardner-Nix J, Goldman B, Hays H, Lynch M, et al. Use of opioid analgesics for the treatment of chronic noncancer pain-a consensus statement and guidelines from the Canadian Pain Society, 2002. Pain Res Manag 2003:8(Suppl A):3A-28A.

Løseth S, Nebuchennykh M, Stålberg E, Mellgren SI. Medial plantar nerve conduction studies in healthy controls and diabetics. Clin Neurophysiol 2007;118:1155-61.

National Institute for Health and Clinical Excellence. Neuropathic pain – the pharmacological management of neuropathic pain in adults in non-specialist settings. London, UK: NICE; 2010. Clinical guideline 96.

Pittler MH, Ernst E. Complementary therapies for neuropathic and neuralgic pain: systematic review. Clin J Pain 2008;24:731-3.

Portenoy RK, Payne R, Passic S. Acute and chronic pain. In: Lowinson JH, et al, eds. Comprehensive Textbook of Substance Abuse. Baltimore, Md: Williams and Wilkins; 2005:863-903.

Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005;6:432-42.

Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M. Identification of cut-points for mild, moderate and severe pain due to diabetic peripheral neuropathy. Pain 2005;115:29-36.

Common Adverse Effects from Drugs Used to Treat Neuropathic Pain: Download PDF

Drug Interactions in the Treatment of Neuropathic Pain: Download PDF

Effect of Comorbidities on Choice of Agent for Neuropathic Pain: Download PDF

Patient Health Questionnaire for Anxiety and Depression (PHQ-4): Download PDF

Neuropathic Pain Screening Tool (DN4): Download PDF

Neuropathic Pain Screening Tool (LANSS): Download PDF

 

 

 

 

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