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NICE backs down on pregabalin restriction for neuropathic pain



NICE has back-tracked on controversial plans to demote pregabalin to second-line use after gabapentin in the management of neuropathic pain, it revealed in updated guidance released this week.

GPs can now offer either pregabalin, gabapentin, amitriptyline or duloxetine as initial treatment in patients with any type of neuropathic pain, with the exception of trigeminal neuralgia for which carbamazepine is the recommended initial treatment.

The decision marks an apparent climb-down by the regulator after it previously announced plans to switch pregabalin for gabapentin as a recommended first-line treatment on the grounds of cost.

NICE initially recommended amitriptyline or pregabalin first-line in treatment options in its first-ever guidance on pharmacological management of neuropathic pain published in 2010, with duloxetine recommended first-line for patients with painful diabetic neuropathy.

But within 18 months it announced a review of the decision on pregabalin, because of cost concerns – and proposed swapping gabapentin as an alternative first-line drug of choice.

However, the newly published final guidance reverses that proposal and leaves the choice down to GPs, with advice on what to try if the initial treatment is ineffective or not tolerated.

Dr Ollie Hart, a GPSI in pain in Sheffield, said the guidance was welcome and would reflect common practice, although he said most GPs would choose gabapentin before pregabalin because of the cost.

He told Pulse: ‘It reflects common practice where often clinicians rotate medications in a trial of “n=1” with the individual patient, with regular review of effects.

‘Most GPs would (and I would recommend) using gabapentin before pregabalin. Cost/value issue make this the sensible decision for most.’

Dr Hart said more detail would have been useful on how long initial treatments should be tried and it was disappointing the off-licence status of cheaper drugs has been highlighted in the guidance.

He said: ‘It would have been more helpful if they had indicated time frames for trailing meds – in reality I often allow two-to-four weeks for evidence of benefit or not.

‘It is a shame that they have chosen to highlight the off-licence aspects of some of the medications- amitriptyline for example has a long a well evidenced history of use in neuropathic pain. We are working in an NHS system where value based decisions have to be made,’ Dr Hart added.

NICE – CG173 Neuropathic pain – pharmacological management