General

Guideline Title

Neuropathic pain - pharmacological management. The pharmacological management of neuropathic pain in adults in non-specialist settings.

Bibliographic Source(s)

National Institute for Health and Care Excellence (NICE). Neuropathic pain - pharmacological management. The pharmacological management of neuropathic pain in adults in non-specialist settings. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. 41 p. (Clinical guideline; no. 173).

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Centre for Clinical Practice. Neuropathic pain. The pharmacological management of neuropathic pain in adults in non-specialist settings. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 155 p. (Clinical guideline; no. 96).

Regulatory Alert

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse : This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

August 31, 2016 – Opioid pain and cough medicines combined with benzodiazepines: A U.S. Food and Drug Administration (FDA) review has found that the growing combined used of opioid medicines with benzodiazepines or other drugs that depress the central nervous system (CNS) has resulted in serious side effects, including slowed or difficult breathing and deaths. FDA is adding Boxed Warnings to the drug labeling of prescription opioid pain and prescription opioid cough medicines and benzodiazepines.

Recommendations

Major Recommendations

Key Principles of Care

When agreeing a treatment plan with the person, take into account their concerns and expectations, and discuss:

The severity of the pain, and its impact on lifestyle, daily activities (including sleep disturbance) and participation 1
The underlying cause of the pain and whether this condition has deteriorated
Why a particular pharmacological treatment is being offered
The benefits and possible adverse effects of pharmacological treatments, taking into account any physical or psychological problems, and concurrent medications
The importance of dosage titration and the titration process, providing the person with individualised information and advice
Coping strategies for pain and for possible adverse effects of treatment
Non-pharmacological treatments, for example, physical and psychological therapies (which may be offered through a rehabilitation service) and surgery (which may be offered through specialist services).

For more information about involving people in decisions and supporting adherence, see Medicines adherence (National Institute for Health and Care Excellence [NICE] clinical guideline 76).

Consider referring the person to a specialist pain service and/or a condition-specific service 2 at any stage (see below), including at initial presentation and at the regular clinical reviews, if:

They have severe pain or
Their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation 1 or
Their underlying health condition has deteriorated.

Continue existing treatments for people whose neuropathic pain is already effectively managed, taking into account the need for regular clinical reviews.

When introducing a new treatment, take into account any overlap with the old treatments to avoid deterioration in pain control.

After starting or changing a treatment, carry out an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.

Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:

Pain control
Impact on lifestyle, daily activities (including sleep disturbance) and participation 1
Physical and psychological wellbeing
Adverse effects
Continued need for treatment

When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

1 The World Health Organization ICF (International Classification of Functioning, Disability and Health) (2001) defines participation as ‘A person’s involvement in a life situation.’ It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.

2 A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.

Treatment

All Neuropathic Pain (Except Trigeminal Neuralgia)

Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia) 3 .

If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

Consider tramadol only if acute rescue therapy is needed.

Consider capsaicin cream 4 for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

3 At the time of publication (November 2013), amitriptyline did not have a UK marketing authorisation for this indication, duloxetine is licensed for diabetic peripheral neuropathic pain only, and gabapentin is licensed for peripheral neuropathic pain only, so use for other conditions would be off-label. In addition, the Lyrica (Pfizer) brand of pregabalin has patent protection until July 2017 for its licensed indication of treatment of peripheral and central neuropathic pain; until such time as this patent expires generic pregabalin products will not be licensed for specific indications and their use may be off-label and may infringe the patent, see summaries of product characteristics of pregabalin products for details. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

4 At the time of publication (November 2013), capsaicin cream (Axsain) had a UK marketing authorisation for post-herpetic neuralgia and painful diabetic peripheral polyneuropathy, so use for other conditions would be off-label. The SPC states that this should only be used for painful diabetic peripheral polyneuropathy ‘under the direct supervision of a hospital consultant who has access to specialist resources’. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.

Treatments That Should Not Be Used

Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so:

Cannabis sativa extract
Capsaicin patch
Lacosamide
Lamotrigine
Levetiracetam
Morphine
Oxcarbazepine
Topiramate
Tramadol (for long-term use)
Venlafaxine

Trigeminal Neuralgia

Offer carbamazepine as initial treatment for trigeminal neuralgia.

If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.

Clinical Algorithm(s)

A NICE pathway on neuropathic pain is available from the National Institute for Health and Care Excellence (NICE) Web site.

Scope

Disease/Condition(s)

Neuropathic pain conditions

Guideline Category

Counseling
Management
Treatment

Clinical Specialty

Endocrinology
Family Practice
Infectious Diseases
Internal Medicine
Neurology
Oncology
Pharmacology
Psychiatry
Psychology
Surgery

Intended Users

Advanced Practice Nurses
Health Care Providers
Nurses
Patients
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians

Guideline Objective(s)

To improve the care of adults with neuropathic pain by making evidence-based recommendations on the pharmacological management of neuropathic pain outside of specialist pain management services
To ensure that people who require specialist assessment and interventions are referred appropriately and in a timely fashion to a specialist pain management service and/or other condition-specific services

Target Population

Adults with neuropathic pain who are treated outside specialist pain management services

Interventions and Practices Considered

Key principles of care * Patient referral to specialist care * Continuation of effective management * Consideration of potential benefits and harms of pharmacological treatment options * Early clinical review assessment of new treatment * Non-pharmacological treatment options * Withdrawing and switching treatment * Monitoring efficacy and side effects
Management of neuropathic pain (except trigeminal neuralgia) * Amitriptyline * Gabapentin * Pregabalin * Duloxetine * Rescue therapy (tramadol) * Capsaicin cream (localized neuropathic pain)
Management of trigeminal neuralgia * Carbamazepine * Referral to specialist pain service

Major Outcomes Considered

Patient-reported global improvement in symptoms
Patient-reported pain relief
Patient-reported improvement in daily physical and emotional functioning, including sleep
Major adverse effects (defined as leading to withdrawal from treatment), and minor adverse effects of the medication
Overall improvement in quality of life
Resource use and costs
Patient satisfaction
Incidence of drug dependence (including withdrawal symptoms)
Incidence of drug abuse or drug misuse

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data

Description of Methods Used to Collect/Select the Evidence

Search Strategies

The evidence reviews used to develop the guideline recommendations were underpinned by systematic literature searches, following the methods described in The guidelines manual (2012 [see the “Availability of Companion Documents” field]). The aim of the systematic searches was to comprehensively identify the published evidence to answer the review questions developed by the Guideline Development Group and Internal Clinical Guidelines Technical Team.

The search strategies for the review questions were developed by the Information Services Team with advice from the Internal Clinical Guidelines Technical Team. Structured questions were developed using the PICO (population, intervention, comparison, outcome) model and translated into search strategies using subject heading and free text terms. The strategies were run across a number of databases with no date restrictions imposed on the searches.

The National Health Service (NHS) Economic Evaluation Database (NHS EED) and the Health Economic Evaluations Database (HEED) were searched for economic evaluations. Search filters for economic evaluations and quality of life studies were used on bibliographic databases. There were no date restrictions imposed on the searches.

Guideline Development Group members were also asked to alert the Internal Clinical Guidelines Technical Team to any additional evidence, published, unpublished or in press, that met the inclusion criteria.

Scoping Searches

When the guideline was initially referred to the National Institute for Health and Care Excellence (NICE), scoping searches were undertaken on the following websites and databases between October 28th and November 3rd 2008 to provide information for scope development and project planning. Browsing or simple search strategies were employed.

The search results were used to provide information for scope development and project planning.

Guidance/Guidelines	Systematic Reviews/Economic Evaluations
Canadian Medical Association Infobase	Cochrane Database of Systematic Reviews (CDSR)
Clinical Evidence	Database of Abstracts of Reviews of Effects (DARE)
Clinical Knowledge Summaries (Prodigy)	Health Economic Evaluations Database (HEED)
Department of Health	Health Technology Assessment (HTA) Database
Guidelines International Network (GIN)	National Institute for Health Research (NIHR) Health Technology Assessment Programme
National Health and Medical	NHS Economic Evaluation Database (NHS EED)
National Institute for Health and Care Excellence (NICE) - published & in development	NHS R&D Service Delivery and Organisation Programme
New Zealand Guidelines Group	The NIHR Health Services and Delivery Research (HS&DR)
NLH Guidelines Finder	Trip Database
NLH Specialist Libraries
Professional bodies/associations/societies (British Pain Society, International Association for the Study of Pain, Chronic Pain Policy Society, Diabetes UK, Multiple Sclerosis Society)
Protocols and Care Pathways Database
Research Council (Australia)
Royal Colleges
Scottish Intercollegiate Guidelines Network (SIGN)
US National Guideline Clearinghouse

Ahead of the development searches in 2012 for the full update of the guideline, additional scoping searches were conducted to identify any new drugs that had been licensed since the initial scoping in 2008. The British National Formulary (BNF), New Drugs Online and the electronic Medicines Compendium websites were searched between 26th and 27th April 2012.

Main Searches

The following sources were searched for the topics presented in the sections below.

CINAHL (EBSCO)
Cochrane Central Register of Controlled Trials – CENTRAL (Wiley)
Cochrane Database of Systematic Reviews – CDSR (Wiley)
Database of Abstracts of Reviews of Effects – DARE (CRD up to May 2009 and Wiley after May 2009)
EMBASE (Ovid)
Health Economic Evaluations Database – HEED (Wiley)
Health Technology Assessment Database – HTA (CRD up to May 2009 and Wiley after May 2009)
MEDLINE (Ovid)
MEDLINE In-Process (Ovid)
NHS Economic Evaluations Database – NHS EED (CRD up to May 2009 and Wiley after May 2009)

Systematic Review Searches

The searches were conducted between 17th and 31st July 2012 and one strategy was designed to identify evidence on the following clinical questions:

What is the clinical effectiveness of different pharmacological treatments as monotherapy compared with each other or placebo for the management of neuropathic pain in adults, outside of specialist pain management services?
What is the clinical effectiveness of different pharmacological treatments as combination therapy compared with other combination therapies, monotherapy or placebo for the management of neuropathic pain in adults, outside of specialist pain management services?

The MEDLINE search strategy is presented in Appendix D in the full version of the original guideline document (see the “Availability of Companion Documents” field) and was translated for use in all of the databases listed above.

Search filters to retrieve reports of randomised controlled trials and systematic reviews were appended to identify relevant evidence.

In addition search filters were also applied to separately identify economic evaluations and quality of life evidence. These searches were conducted between 23rd and 29th August 2012.

Systematic Review of Published Economic Evaluations

A systematic review for cost-effectiveness evidence was undertaken for this guideline.

Information Sources

The following databases were searched for economic evidence: NHS Economic Evaluation Database (NHS EED), and the Health Economic Evaluations Database (HEED). MEDLINE, MEDLINE (in-process) and EMBASE were searched using a validated economic filter to ensure any non-indexed economic studies were identified. No date filters were applied. The search strategies for health economics are included in Appendix D in the full version of the original guideline document (see the “Availability of Companion Documents” field).

Selection Criteria for Included Evidence

Studies that compared the costs and health consequences (cost–utility analyses) of different strategies in terms of an incremental cost effectiveness ratio, or net benefit, were included. All other study types (cost-effectiveness, cost–benefit, cost–consequence, and comparative costing studies) were excluded.

Studies conducted in Organisation for Economic Co-operation and Development (OECD) countries were included.

Studies that met the NICE reference case criteria (The guidelines manual, 2012 [see the “Availability of Companion Documents” field]) for applicability and quality were included. The health economist sifted the literature search results by comparing the title and abstract of the study with the selection criteria and PICO question.

Posters, reviews and letters, non-English studies and unpublished studies were excluded. Duplicates were excluded, and if identical study designs were available but from a different setting, the study closest to the NHS and Personal Social Services (PSS) setting was included and the other excluded.

See Appendix F in the full version of the original guideline document for assessment of applicability and quality of studies.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Overall Quality of Outcome Evidence in Grading of Recommendations Assessment, Development and Evaluation (GRADE)

Level	Description
High	Further research is very unlikely to change confidence in the estimate of effect
Moderate	Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate
Low	Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate
Very Low	Any estimate of effect is very uncertain

Methods Used to Analyze the Evidence

Meta-Analysis
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Data Extraction

Time-points

The included evidence reported a variety of follow-up periods. In order to enable the comparison of studies with different follow-up periods, the Guideline Development Group (GDG) felt it important to extract outcomes at common time-points. Given the number and heterogeneity of the time-points reported in the literature, it was important to prioritise which time-points were extracted, while maintaining the ability to compare studies. Before data extraction commenced, the time-points where outcomes data were reported across the available literature were mapped and common time-points across the studies were chosen. The resulting time-points where outcomes were then extracted from the literature.

Measurement Tools Extracted

A large number of different measurement tools were used in the literature for a number of critical and important outcomes (particularly global improvement, physical and emotional functioning and pain). The tools for which data were extracted were those prioritised by the GDG, based on clinical relevance, the reliability and validity of the tools for measuring particular outcomes, and the frequency to which they appeared in the literature.

See Appendix D in the full version of the original guideline document (see the “Availability of Companion Documents” field) for more information about time-points and measurement tools extracted.

Synthesis Methods

Where possible, meta-analyses were conducted to combine the results of studies for each outcome.

Pairwise meta-analyses were performed using a frequentist approach in Excel.

Network meta-analyses (NMAs) were conducted to simultaneously compare multiple treatments in a single meta-analysis, preserving the randomisation of the randomised controlled trials included in the reviews. This allows all evidence to be combined in a single internally consistent model. A mixed/multiple treatment comparison (MTC) combines both direct and indirect evidence to reduce uncertainty where there are few head-to-head trials, and also provides coherence in the effect estimate producing a more robust estimate of effect. These were used when there were data available on more than two interventions. When there were data available on only two interventions which were not connected by head-to-head evidence, a simple type of network meta-analysis, an indirect treatment comparison (ITC), was used to provide an indirect estimate of the treatment effect between both interventions.

A hierarchical Bayesian NMA was performed using the software WinBUGS version 1.4.3. The models were based on the approach and code provided in the NICE Decision Support Unit’s Technical Support Documents on evidence synthesis, particularly Technical Support Document 2 (‘A generalised linear modelling framework for pairwise and network meta-analysis of randomised controlled trials’; see http://www.nicedsu.org.uk/).

See Appendix D in the full version of the original guideline document (see the “Availability of Companion Documents” field) for information about choice of model; dichotomous, continuous, and categorical outcomes; prior distributions; running the model; outputs of network meta-analyses; and assessing how well the model fit the data.

Quality Assessment

Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for the chosen outcomes as specified in the Guidelines Manual. See Appendix D in the full version of the original guideline document (see the “Availability of Companion Documents” field) for more information.

Undertaking Health Economic Analysis

A de novo health economic model was built to inform the GDG’s decision making. Full details are provided in Appendix F in the full version of the original guideline document and a summary of methods and results is provided in section 3.1.3 in the full version of the original guideline document (see the “Availability of Companion Documents” field).

Original Health Economic Model – Methods

The model assessed the costs and effects of all treatments in the assembled effectiveness and safety evidence base for which sufficient data were available. To be included in the model, at least 1 estimate of dichotomous pain relief (30% and/or 50% relief compared with baseline) and data on withdrawal due to adverse effects were required. In total, 17 treatments met these criteria. See Appendix F in the full version of the original guideline document (see the “Availability of Companion Documents” field) for full details of the modelling carried out for the guideline.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Forming and Running the Short Clinical Guideline Development Group (GDG)

Each short clinical guideline is developed by a unique GDG consisting of 8 to 12 members, supported by the Internal Clinical Guidelines Programme technical team at NICE. Each GDG has a Chair, healthcare professional members and a minimum of two patient and carer members. Co-opted expert advisers are recruited as appropriate. A Clinical Adviser, who has specific content expertise and additional responsibilities, may be appointed depending on the topic. Recruitment of the GDG Chair and members is carried out in accordance with NICE’s policy ‘Appointments to guidance producing bodies advisory to NICE’ (November 2006). The development phase of the guideline takes 4–6 months, and the GDG meets approximately every 4 to 6 weeks.

Developing Review Questions

A short clinical guideline has a narrow scope and covers only part of a care pathway. It addresses approximately three subject areas covering clinical management. This will result in a small number of key clinical issues (listed in the scope). These are broken down into a defined number of review questions – usually one or two per clinical management area. The exact number will be dictated by the size of the short clinical guideline remit and the amount of development time available. As with the standard clinical guideline programme, it is feasible to present a maximum of two systematic reviews per day at a GDG meeting. These review questions are formulated and structured according to the process for standard clinical guidelines.

Creating Guideline Recommendations

The smaller number of review questions results in a smaller number of guideline recommendations. The number of recommendations in each short clinical guideline is likely to be between 5 and 20. Research recommendations are formulated for short clinical guidelines. Their number is dependent on the size of the short clinical guideline remit.

Writing the Guideline

The full guideline is written by the Internal Clinical Guidelines Programme technical team, following the principles in chapters 9 and 10 of ‘The guidelines manual’ (see the “Availability of Companion Documents” field). The NICE guideline, NICE pathway and ‘Information for the public’ are written by NICE editors.

See Appendix M of The guidelines manual (2012) (see the “Availability of Companion Documents” field) for more information.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group (GDG) makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the GDG is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

Interventions That Must (or Must Not) Be Used

The GDG usually uses ‘must’ or ‘must not’ only if there is a legal duty to apply the recommendation. Occasionally ‘must’ (or ‘must not’) is used if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions That Should (or Should Not) Be Used – a ‘Strong’ Recommendation

The GDG uses ‘offer’ (and similar words such as ‘refer’ or ‘advise’) when confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost-effective. Similar forms of words (for example, ‘Do not offer…’) are used when the GDG is confident that an intervention will not be of benefit for most patients.

Interventions That Could Be Used

The GDG uses ‘consider’ when confident that an intervention will do more good than harm for most patients, and be cost-effective, but other options may be similarly cost-effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient’s values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Cost Analysis

In general, an intervention is considered to be cost-effective if either of the following criteria applies:

The intervention dominates other relevant strategies (that is, is both less costly in terms of resource use and more clinically effective than all the other relevant alternative strategies), or
The intervention costs less than £20,000 per quality adjusted life year (QALY) gained than the next best strategy.

A health economic analysis was developed to support the Guideline Development Group (GDG) in making recommendations. The analysis was conducted according to National Institute for Health and Care Excellence (NICE) methods outlined in the ‘The guidelines manual 2012’ and ‘Guide to the methods of technology appraisals 2008’. It follows the NICE reference case (the framework NICE requests all cost-effectiveness analysis follow) in its methods.

A systematic review of published cost–utility analyses found inconsistent and, at times, contradictory results from a heterogeneous group of studies, each of which addressed a small subgroup of potentially relevant comparators. Therefore, the GDG’s health economic considerations were predominantly based on the de novo health economic model devised for this guideline.

The references to included studies and the respective evidence tables with the study characteristics and results are provided in Appendix F in the full version of the original guideline (see the “Availability of Companion Documents” field).

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

The guideline was validated through two consultations.

The first draft of the guideline (the full guideline and National Institute for Health and Care Excellence [NICE] guideline) were consulted with Stakeholders and comments were considered by the Guideline Development Group (GDG).
The final consultation draft of the full guideline, the NICE guideline and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate pharmacological management of adults with neuropathic pain

Potential Harms

Adverse effects of pharmacological treatments, including potential for dependence

The guideline will assume that prescribers will use a drug’s summary of product characteristics (SPC) and the British National Formulary (BNF) to inform decisions made with individual patients (this includes obtaining information on special warnings, precautions for use, contraindications and adverse effects of pharmacological treatments).

Contraindications

Qualifying Statements

This guidance represents the view of the National Institute for Health and Care Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
For all drugs, recommendations are based on evidence of clinical and cost effectiveness and reflect whether their use for the management of neuropathic pain is a good use of National Health Service (NHS) resources. This guideline should be used in conjunction with clinical judgement and decision-making appropriate for the individual patient.
The guideline will assume that prescribers will use a drug’s summary of product characteristics (SPC) and the British National Formulary (BNF) to inform decisions made with individual patients (this includes obtaining information on special warnings, precautions for use, contraindications and adverse effects of pharmacological treatments). However, the Guideline Development Group (GDG) agreed that having clear statements on drug dosage and titration in the actual recommendations is crucial for treatment in non-specialist settings, to emphasise the importance of titration to achieve maximum benefit.
Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the patient is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health’s advice on consent. If someone does not have the capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in Patient experience in adult NHS services.
For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision.
This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The service user (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information. Where recommendations have been made for the use of drugs outside their licensed indications (‘off-label use’), these drugs are marked with a footnote in the recommendations.

Implementation of the Guideline

Description of Implementation Strategy

The National Institute for Health and Care Excellence (NICE) has developed tools to help organizations implement this guidance. These are available on the NICE Web site (see also the “Availability of Companion Documents” field).

Implementation Tools

Clinical Algorithm
Mobile Device Resources
Patient Resources
Resources

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

National Institute for Health and Care Excellence (NICE). Neuropathic pain - pharmacological management. The pharmacological management of neuropathic pain in adults in non-specialist settings. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. 41 p. (Clinical guideline; no. 173).

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2010 Mar (revised 2013 Nov)

Guideline Developer(s)

National Institute for Health and Care Excellence (NICE) - National Government Agency [Non-U.S.]

Source(s) of Funding

National Institute for Health and Care Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members : Damien Longson ( Guideline Chair ), Consultant Liaison Psychiatrist; Issak Bhojani, General Practitioner, Blackburn with Darwen; Brigitta Brandner, Consultant in Anaesthesia and Pain Management, University College London Hospital’s Trust; Karen Cavanagh, Patient and carer member; MunSeng Chong, Consultant Neurologist, National Hospital for Neurology and Neurosurgery, University College London Hospitals; Marie Fallon, St Columba’s Hospice Chair of Palliative Medicine, University of Edinburgh (until April 2013); Annette Gibb, Nurse Consultant in Pain Management, Royal Berkshire NHS Foundation Trust; Paul Howard, Consultant in Palliative Medicine, Berkshire West Palliative Care Service; Charles Lane, General Practitioner, The Wirral (until March 2013); Ammy Pui-Chi Lam, Clinical Pharmacist in Critical Care, Anaesthetics and Pain, Bart’s and the London NHS Trust; Vera Neumann, Consultant and Honorary Senior Lecturer in Rehabilitation Medicine, Leeds Teaching Hospital, NHS Trust and The University of Leeds (until October 2013); Sailesh Sankaranarayanan, Consultant Physician in Diabetes and Endocrinology, University Hospitals of Coventry and Warwickshire; Heather Wallace, Patient and carer member

Co-opted Members : The following people were not full members of the Guideline Development Group but were coopted onto the group as expert advisers: Solomon Tesfaye, Consultant Diabetologist, Royal Hallamshire Hospital, Sheffield

Financial Disclosures/Conflicts of Interest

Appendix A in the full version of the original guideline document contains a declaration of interests for all members of the Guideline Development Group (GDG).

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the National Institute for Health and Care Excellence (NICE) Web site.

Availability of Companion Documents

The following are available:

Neuropathic pain - pharmacological management. Full guideline. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. 138 p. (Clinical guideline; no. 173). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Care Excellence (NICE) Web site.
Neuropathic pain - pharmacological management. Appendices. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. Various p. (Clinical guideline; no. 173). Electronic copies: Available in PDF from the NICE Web site.
Neuropathic pain - pharmacological management. Costing statement. Implementing NICE guidance. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. 7 p. (Clinical guideline; no. 173). Electronic copies: Available in PDF from the NICE Web site.
Neuropathic pain - pharmacological management. Baseline assessment tool. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. (Clinical guideline; no. 173). Electronic copies: Available from the NICE Web site.
The guidelines manual 2012. London (UK): National Institute for Health and Care Excellence (NICE); 2012 Nov. Electronic copies: Available from the NICE Archive Web site.

Patient Resources

The following is available:

Drug treatments for neuropathic pain. Information for the public. London (UK): National Institute for Health and Care Excellence (NICE); 2013 Nov. (Clinical guideline; no. 173). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Care Excellence (NICE) Web site. Also available for download as a Kindle or EPUB ebook from the NICE Web site.

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NGC Status

This summary was completed by ECRI Institute on January 17, 2011. This NGC summary was updated by ECRI Institute on April 16, 2014. This summary was updated by ECRI Institute on June 2, 2016 following the U.S. Food and Drug Administration advisory on Opioid pain medicines. This summary was updated by ECRI Institute on October 21, 2016 following the U.S. Food and Drug Administration advisory on opioid pain and cough medicines combined with benzodiazepines. This summary was updated by ECRI Institute on June 22, 2017 following the U.S. Food and Drug Administration advisory on Codeine and Tramadol Medicines.

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