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Top 10 tips: Neuropathic pain

Dr Brian Crichton passes on his tips for understanding and management

Dr Brian Crichton passes on his tips for understanding and management

1 Neuropathic pain has big implications.

Neuropathic pain has a prevalence of up to 1.5 per cent in the published literature and can have a huge effect on patients' and carers' lives. We as GPs are extremely well placed to help patients as we offer the first point of medical contact.

2 Early recognition and effective treatment of pain and its antecedents are vital for successful outcomes.

This helps prevent CNS maladaptation and reduces the probability of pain becoming chronic. The best way to treat neuropathic pain is not to get it in the first place.

3 Look for the hallmark symptoms.

Neuropathic pain is caused by damage to the central nervous system (CNS) with the two commonest causes being diabetes and herpes zoster neuralgia. The symptoms are described as burning, electric, tingling and shooting in nature and can be paroxysmal or continuous. However, the hallmark symptoms are allodynia (pain created by a stimulus that does not ordinarily produce pain) and hyperalgesia (increased sensitivity to a normal pain stimulus).

4 Once peripheral nerves are damaged they behave abnormally in patients with neuropathic pain.

This can cause pain to persist long after the nerves have healed, owing to changes that have occurred within the CNS leading to a chronic pain syndrome.

5 Numerous treatment options are available such as topical, systemic, physical (for example, physical rehabilitation), psychological (behaviour modification, relaxation therapy) and invasive (trigger point injections).

A combination (multimodal) approach achieves best results.

6 Tricyclic antidepressants have been successfully used for over 25 years.

Amitriptyline (unlicensed in the UK for chronic pain), unlike its use in depression, can be started at a dose of 10mg in the evening and titrated upwards in 10mg increments every three days to a maximum of 50mg. The onset of analgesia occurs over days rather than weeks. When side-effects are particularly a problem nortriptyline (unlicensed) can be considered.

7 Anticonvulsants are particularly effective for burning and lancinating pains.

As a first line I use carbamazepine, and the combination with tricyclic antidepressants can be synergistic.

8 Gabapentin and pregabalin can be useful but are expensive.

They are well tolerated and can be titrated. This is straightforward with pregabalin, though trials are predominantly against placebo and therefore, I think, should be second line.

9 Consider topical capsaicin.

Capsaicin is thought to deplete substance P in nerve endings. It has very low systemic absorption but must be applied four times a day. Pain relief can take a few weeks and there may be skin reactions.

10 Opioids were thought ineffective in neuropathic pain.

But recent studies show they can be effective in higher doses. Titrate up the dose so that efficacy is balanced against side-effects.

Brian Crichton is a GP in Solihull, West Midlands, and a GP trainer. He is honorary teaching fellow at Warwick University and a lecturer in therapeutics in primary care.Competing interests none declared

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