This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go summarise the pharmacological management of neuropathic pain reviewing the guidelines on Neuropathic Pain and, because of the overlap in the clinical areas, also the guideline on Low Back Pain and Sciatica, both by the National Institute for Health and Care Excellence (NICE).
I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.
There is a YouTube version of this and other videos that you can access here:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The link to the PDF summary can be downloaded here:
· https://1drv.ms/b/s!AiVFJ_Uoigq0mEiBizIQiitY4as7?e=HS9lhY
The Full NICE guidance can be found at:
· Neuropathic pain : https://www.nice.org.uk/guidance/cg173
· Low back pain and sciatica: https://www.nice.org.uk/guidance/ng59
Pictures:
· Image by kjpargeter on Freepik: a href="https://www.freepik.com/free-photo/3d-female-with-pain-head_1270692.htm#query=neuropathic%20pain&position=0&from_view=search&track=ais"Image by kjpargeter/a on Freepik
· Image by kjpargeter on Freepik: a href="https://www.freepik.com/free-photo/3d-brain-with-lightening_6214247.htm#query=neuropathic%20pain&position=45&from_view=search&track=ais"Image by kjpargeter/a on Freepik
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
Transcript
Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE guideline on neuropathic pain and, because of a slight clinical overlap, I will also touch on the management of sciatica. Please note that I will only be focusing on the pharmacological treatment from a primary care perspective.
So let’s jump into it.
And we will start with a very straightforward condition: trigeminal neuralgia.
And for this, we will offer carbamazepine initially 100mg once or twice a day, increasing gradually according to response. The usual dose is 200mg 3-4 times a day but it can be increased to a maximum of 1.6 gr daily in divided doses. Of course, we will bear in mind that there is a risk of major congenital malformations in pregnancy and advise contraception accordingly.
And we have nothing else to offer in primary care so, if carbamazepine is not effective, or suitable, we will need to refer.
For all other neuropathic pain
We will discuss with the patient whether to give oral or topical treatment.
And if the neuropathic pain is localised and they wish to avoid or cannot tolerate oral treatments, we will consider capsaicin cream.
Otherwise, we will offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as the initial treatment. Gabapentin and pregabalin are controlled drugs so it would make sense to start with either amitriptyline or duloxetine first to minimise the risk of dependency.
If the initial treatment is not effective or tolerated, we will offer one of the remaining 3 drugs, and consider switching again if the second and third drugs are also not effective or not tolerated.
And, as a general rule, when withdrawing or switching treatment, we will taper the dose to minimise any withdrawal symptoms.
So, for me, considering the cost of drugs and risk of dependency, I would consider:
1. Amitriptyline first
2. Then duloxetine,
3. Then gabapentin and
4. Lastly pregabalin
We will refer if despite treatment the pain is severe, disabling or affecting their sleep or if their underlying condition has deteriorated.
As acute rescue therapy, we could consider tramadol, but only for short term use.
The rest of the guidelines is going to sound like this:
No, no, no, no, no
Because it is going to tell us what treatments should not be used. And we should not start:
· cannabis extract
· capsaicin patch
· opiates like morphine and tramadol (this is referring to long-term use; because careful short-term use of tramadol is allowed)
· venlafaxine
· antiepileptics such as lacosamide, lamotrigine, levetiracetam, oxcarbazepine, topiramate or sodium valproate
For sciatica, there is a separate guideline.
And from a Pharmacological perspective, we are very limited because nothing really seems to work very well in sciatica.
We can give NSAIDs but we need to be aware of their risks and limited evidence that they are of much benefit.
If prescribing NSAIDs for sciatica:
· We will take into account gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age
· think about risk factors, and the use of gastroprotective treatment
· use the lowest effective dose for the shortest possible time.
Can we use anything else if NSAIDs do not work?
For acute low back pain, we can consider weak opioids (with or without paracetamol) but only when managing acute low back pain and only if an NSAID hasn’t worked or can’t be used. We should not offer paracetamol alone for low back pain.
But we should not be giving opioids for on-going, non-acute sciatica
For chronic sciatica, if NSAIDs are not effective, we are going to encounter the same as before.
So, we should not offer:
· Gabapentinoids
· other antiepileptics
· oral corticosteroids
· benzodiazepines
· opioids
If a person is already taking any of these drugs, we will consider a safe and gradual withdrawal regime
Although we are focusing on the pharmacological treatment, I would like to say that we should also discuss non-pharmacological treatments, for example, physical and psychological therapies and surgery.
We will advise self-management and appropriate exercise, including return to work programmes if possible.
Psychological therapy or manual therapies like spinal manipulation or massage should be offered only as part of a treatment package including exercise and
Combined physical and psychological programmes should be offered for people with persistent and significant symptoms that have not responded to treatment.
We should not offer:
· Orthotics such as belts, corsets or foot orthotics
· Traction
· Acupuncture
· Ultrasound
· Electrical nerve simulation, either percutaneous or transcutaneous (PENS or TENS)
We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
