The guideline starts stating that neuropathic pain develops as a result of damage to, or dysfunction of, the system that normally signals pain. It may arise from a heterogeneous group of disorders affecting the peripheral and central nervous systems. Furthermore that neuropathic pain may present with altered pain  sensation, areas of numbness or burning, and continuous or intermittent spontaneous pain. It is an unpleasant sensory and emotional experience that 8 can have a significant impact on a person’s quality of life. 

Neuropathic pain difficult to treat

Neuropathic pain is often difficult to treat, we can read in the guideline, because it is resistant to many medications and/or because of the adverse events that the medications cause. 

Patients are partners

The guideline clearly states that doctors should see themselves as coaches: People with neuropathic pain should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. 

The guideline gives specific recommendations on how to communicate with our patients:

Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate.  

First step in the treatment neuropathic pain

The guideline pleads for a first step using pregabeline and amitriptyline, that is precisely the first step we take in our site since many years. Amitriptyline is clearly the most superior painkiller, but patients suffer from its side effects. Therefore we start treating often with a combination of these drugs in relative low dosages. For neuropathic pain due to ciabetes, the guideline suggests to start with duloxetine. That is not our most prefered drug, as its efficacy in our hands seems a bit lower compared to the other above mentioned drugs, which are also our first choices for diabetic painful neuropathy.

The recommendation of the guideline to increase the dose of duloxetine is also not supported by the literature. It does not make sense, as the efficacy is not increasing, while the side efects do increase.  

In case of amitriptyline results in satisfactory pain reduction but the person cannot tolerate the adverse effects select oral nortriptyline or imipramine.

Combination rather than Step by step 

The guideline is a bit conservative, in that they support monotherapy first....their recommendation in case of insufficient effect is:

If first-line treatment was with amitriptyline, switch to or combine with oral pregabalin.

If first-line treatment was with duloxetine for people with painful diabetic neuropathy, switch to or combine with oral pregabalin.

If first-line treatment was with pregabalin, switch to or combine with oral amitriptyline.  

We would argue to directly start low dose of both first choice analgesics together.

In case of insufficient effect the guideline than recommends Tramadol (start of 50 mg).

Not a word so far on transdermal routes such as the application of analgesic creams.

For drugs or anagesics which are older, and for which no pharmaceutical company is interested to conduct studies the guideline is quite negative. For instance fenytoine, a old timer sometimes realy an help for patients suffering from refractory neuropathic pain the guideline is negative:

No study on phenytoin met the inclusion and exclusion criteria. Therefore there was no appropriate evidence that phenytoin is clinically effective in treating neuropathic pain.  

That is a bit too quick: patients can be treated succesfully with drugs for which high quality trials are not available, because the trials were conducted 40-30 years ago! 

The guideline states as a summary the key principles of care.

Regular monitoring patients suffering from neuropathic pain

Th guideline was clear in the importance to see patients on a regular base:

..the guideline also stressed that regular clinical reviews are important to assess and monitor drug titration, tolerability, adverse effects and the need to continue treatment. This principle should apply to all treatments throughout the care pathway to ensure that patients receive appropriate care.      

Key principles of care 

• Address the person’s concern and expectations when agreeing which treatment to use by discussing: 

- the benefits and possible adverse effects of each treatment 

- coping strategies for pain and possible adverse effects. 

• Explain both the importance of dosage titration and the titration process, providing written information if possible. 

• If the person or the healthcare professional (during the regular clinical reviews) identifies unsatisfactory pain reduction or deterioration in the underlying 

health condition, follow the care pathway or refer the person to a specialist pain service and/or a condition-specific service. 

• When selecting pharmacological treatments, take into account: 

- the person’s vulnerability to specific adverse effects because of comorbidities or age (for example, vulnerability to falls) 

- any mental health problems (such as depression and/or anxiety) 

- lifestyle factors (such as occupation) 

- patient preference 

- current medication. 

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

• When introducing a new treatment, consider an overlap of treatments to avoid deterioration in pain control. 

• After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects, to assess the suitability of the 

chosen treatment. 

• Continue existing treatments for people whose neuropathic pain is already effectively managed.