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Neuropathic pain Implementing NICE guidance March 2010 NICE clinical guideline 96.

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Presentation on theme: "Neuropathic pain Implementing NICE guidance March 2010 NICE clinical guideline 96."— Presentation transcript:

1 Neuropathic pain Implementing NICE guidance March 2010 NICE clinical guideline 96

2 What this presentation covers Background Scope Definitions Recommendations Costs and savings Discussion Find out more

3 Background Neuropathic pain: result of damage to, or dysfunction of the system that normally signals pain Examples: trigeminal neuralgia, diabetic neuropathy, post-herpetic pain Potential difficulties: resistance to medication, side effects Prevalence: estimates vary – different definitions, methods of assessment, patient selection

4 Scope Adults with neuropathic pain conditions Not including those who are treated in specialist pain services or first 3 months after trauma or orthopaedic surgery

5 Definitions Non-specialist settings Specialist pain services Condition-specific services Participation Off-label medicines

6 Consider referral to a specialist pain service and/or a condition-specific service if: pain is severe or pain significantly limits daily activities and participation or underlying health has deteriorated. Key principles of care: 1

7 Continue existing treatments for people whose neuropathic pain is already effectively managed Key principles of care: 2

8 Address the persons concerns and expectations about treatment options, including: benefits and adverse effects why a particular treatment is chosen coping strategies non-pharmacological treatments Key principles of care: 3

9 When selecting pharmacological agents consider: vulnerability to adverse effects safety patient preference lifestyle mental health problems other medication Key principles of care: 4

10 Explain importance of dosage titration and the titration process When withdrawing or switching treatment, taper the withdrawal regimen When introducing a new treatment, consider overlap with the old treatments Key principles of care: 5

11 Early clinical review after starting or changing treatment Regular clinical reviews to assess and monitor treatment effectiveness. Assess: –pain reduction –adverse effects –daily activities and participation –mood –quality of sleep –overall improvement Key principles of care: 6

12 Offer oral amitriptyline* or pregabalin Amitriptyline*: start at 10 mg/day; gradually titrate to maximum of 75 mg/day Pregabalin: start at 150 mg/day (two doses; consider lower starting dose if appropriate); titrate to maximum of 600 mg/day First-line treatment

13 Offer oral duloxetine: start at 60 mg/day (a lower starting dose may be appropriate for some people); titrate to effective dose or maximum tolerated dose – maximum 120 mg/day If duloxetine is contraindicated, offer oral amitriptyline* First-line treatment: diabetic neuropathy

14 Early and regular reviews: satisfactory improvement – continue the treatment; improvement sustained – consider reducing dose first-line amitriptyline* gives satisfactory pain reduction but adverse effects not tolerated – consider oral imipramine* or nortriptyline* First-line treatment: review

15 If maximum tolerated dose of first-line treatment doesnt give satisfactory pain reduction, then after informed discussion: offer another drug as an alternative or offer another drug in combination with the original Second-line treatment

16 If satisfactory pain reduction is not achieved with second- line treatment: refer to a specialist pain service and/or a condition- specific service and consider additional or alternative treatment options while waiting for referral Third-line treatment

17 Do not start opioids other than tramadol without specialist assessment Medicines started by a specialist service may be continued in a non-specialist setting, subject to agreement and planning Other treatments

18 Costs Because of uncertainty about the prevalence and incidence of neuropathic pain, limited data on current prescribing practice and uncertainty around future practice, it is has not been possible to estimate the national cost of implementation of this guideline.

19 Discussion How do our current prescribing patterns for neuropathic pain compare with the guidance? How will our referrals to specialist pain services and condition-specific services change as a result of this guidance? What coping strategies do we currently discuss with patients and how should this change? How do we record the key elements of clinical review?

20 NHS Evidence

21 Find out more Visit the guideline the quick reference guide Understanding NICE guidance costing statement audit support

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