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Neuropathic Pain Therapy: Evidence-Based Recommendations

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Published in Lancet Neurol 2015 Feb 14:162

Authors: Finnerup NB et al.

Results of a meta-analysis and systematic review

Neuropathic pain is a serious chronic condition affecting quality of life that can be relieved but not cured. The estimated prevalence is at least 1% to 5% of the general population (Pain Pract 2014; 14:283). Neuropathic pain results from lesions or disease affecting the somatosensory nervous system, either in the periphery or centrally.

To examine the effect of various treatments for neuropathic pain, researchers conducted a systematic review and meta-analysis of randomized, double-blind studies of oral and topical medications. Studies published in peer-reviewed journals since 1966, as well as unpublished trials retrieved from ClinicalTrials.gov and those from websites of pharmaceutical companies, were included.

On the basis of this analysis, the authors recommend as first-line neuropathic pain therapy tricyclic antidepressants, serotonin–noradrenaline reuptake inhibitors, pregabalin, and gabapentin. They propose that lidocaine patches can be used as second-line therapy (no longer as first-line therapy, because of poor evidence quality), as can high-concentration capsaicin patches and tramadol. The authors make a weak recommendation for strong opioids and botulinum toxin as third-line therapy (rather than first- or second-line, because of adverse effects). They make a weak recommendation against cannabinoids for neuropathic pain

Comment
This is a much-needed update of evidence-based recommendations regarding neuropathic pain treatment. Comorbidities like anxiety and depression need to be considered when choosing the best treatment for an individual patient. Although combination therapies are used, evidence for effectiveness of the various combinations is weak. Similar to this report, the National Institute for Health and Care Excellence guidelines (http://www.nice.org.uk/cg173) recommend amitriptyline, duloxetine, gabapentin, and pregabalin as first-line treatment for the management of most neuropathic pain syndromes.

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