New global research has led to revised international treatment guidelines for neuropathic pain, with updated evidence on the efficacy and safety of both drug and non-drug therapies.
Neuropathic pain, caused by damage to the nervous system from disease, surgery or trauma, is said to affect 10% of Australians.
The systematic review, published in The Lancet Neurology, analysed data from 313 randomised controlled trials involving nearly 50,000 adults.
Led by the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the study offers the most comprehensive analysis to date.
“In Australia, up to 1 in 10 people live with neuropathic pain – these conditions, such as diabetic peripheral neuropathy, postherpetic neuralgia and chemotherapy-induced nerve pain — severely impact quality of life and have a substantial social and economic burden,” says Doctoral researcher at the Centre for Pain IMPACT at Neuroscience Research Australia (NeuRA), and the School of Health Sciences UNSW, Michael Ferraro.
“There is an unmet need for effective and safe treatments for neuropathic pain.
“Our research looked at the evidence for all drugs and nerve stimulation treatments, considering effectiveness, safety, cost, accessibility, and patient perspectives.”
Treatment recommendations
The research report made recommendations for first-, second- and third-line treatments.
“Three medication classes were recommended for first line use,” says Mr Ferraro said.
“These were alpha-2 delta ligands (e.g., pregabalin, gabapentin), serotonin and norepinephrine reuptake inhibitors (e.g., duloxetine), and tricyclic antidepressants (e.g., amitriptyline).
“Importantly, these medicines have only modest benefits and require careful patient screening and close monitoring.
“We also established capsaicin and lidocaine patches and capsaicin cream as second-line therapies despite small effects on pain — they are safe and tolerable, and suitable for use in older adults or patients taking multiple medications.”
The report also included recommendations for non-invasive brain stimulation (repetitive transcranial magnetic stimulation) and advised against cannabis-based products, which were found to be ineffective.
“We did not find sufficient evidence to recommend for or against use of several treatments including selective serotonin reuptake inhibitors (e.g., escitalopram), NMDA receptor antagonists (e.g., ketamine), and implanted spinal cord stimulation,” says Mr Ferraro.
“We recommended against use of cannabis-based products as they were found to be ineffective.”
Treatment decisions should reflect individual need
Mr Ferraro says treatment decisions should reflect individual patient needs.
“Neuropathic pain affects people differently, so the guideline supports the provision of high-quality patient-centred care, that considers needs, values and preferences,” he says.
“Treatment choices depend on potential effectiveness, safety, accessibility, comorbidities, and use of other medicines.”
Future revisions of the guidelines
Mr Ferraro says future revisions of the guidelines may include a focus on other non-drug, non-surgical interventions.
“High-quality evidence on treatment of neuropathic pain with non-drug treatments, such as exercise, is lacking, and should be prioritised for future research,” he says.
The recommendations are intended for use by a broad range of health-care professionals, including pharmacists and healthcare professionals in specialist and primary care settings.
The full report is available here.
