Latest Guidance UpdatesMay 2021–July 2022: In the relevant sections, reference was added to the Medicines and Healthcare products Regulatory Agency (MHRA) safety advice on pregabalin in pregnancy, NICE's guideline on medicines associated with dependence, and the updated MHRA safety advice on antiepileptic drugs in pregnancy
September 2020: Advice on treating sciatica was reviewed and moved to the NICE guideline on low back pain and sciatica.
MHRA advice on antiepileptic drugs in pregnancy: In May 2021, NICE linked to the MHRA updated safety advice on antiepileptic drugs in pregnancy in the recommendation on initial treatment for trigeminal neuralgia. In July 2022, NICE linked to the MHRA safety advice on pregabalin risks during pregnancy in the additional information for the recommendation on initial treatment for all neuropathic pain except trigeminal neuralgia.
MHRA advice on valproate: In April 2018, NICE added warnings that valproate must not be used in pregnancy, and only used in girls and women when there is no alternative and a pregnancy prevention plan is in place. This is because of the risk of malformations and developmental abnormalities in the baby. See the full guideline's update information for details. The MHRA has published temporary advice on the valproate pregnancy prevention programme during the COVID-19 pandemic.
This Guidelines summary covers managing neuropathic pain (nerve pain) with pharmacological treatments in adults in non-specialist settings. It aims to improve quality of life for people with conditions such as neuralgia, shingles, and diabetic neuropathy by reducing pain and promoting increased participation in all aspects of daily living. The guideline sets out how drug treatments for neuropathic pain differ from traditional pain management.
Reflecting on your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
Key Principles of Care
For guidance on safe prescribing and managing withdrawal of antidepressants and dependence-forming medicines, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
- When agreeing a treatment plan with the person, take into account their concerns and expectations, and discuss:
- the severity of the pain, and its impact on lifestyle, daily activities (including sleep disturbance) and participation[A]
- the underlying cause of the pain and whether this condition has deteriorated
- why a particular pharmacological treatment is being offered
- the benefits and possible adverse effects of pharmacological treatments, taking into account any physical or psychological problems, and concurrent medications
- the importance of dosage titration and the titration process, providing the person with individualised information and advice
- coping strategies for pain and for possible adverse effects of treatment
- non-pharmacological treatments, for example, physical and psychological therapies (which may be offered through a rehabilitation service) and surgery (which may be offered through specialist services).
For more information about involving people in decisions and supporting adherence, see the NICE guideline on medicines adherence.
- Consider referring the person to a specialist pain service and/or a condition-specific service[B] at any stage, including at initial presentation and at the regular clinical reviews, if:
- they have severe pain or
- their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation[A] or
- their underlying health condition has deteriorated.
- Continue existing treatments for people whose neuropathic pain is already effectively managed, taking into account the need for regular clinical reviews.
- When introducing a new treatment, take into account any overlap with the old treatments to avoid deterioration in pain control.
- After starting or changing a treatment, carry out an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.
- Carry out regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:
- pain control
- impact on lifestyle, daily activities (including sleep disturbance) and participation[A]
- physical and psychological wellbeing
- adverse effects
- continued need for treatment.
- When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.
All Neuropathic Pain (Except Trigeminal Neuralgia)For guidance on safe prescribing and managing withdrawal of antidepressants and dependence-forming medicines, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
- Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia).[C],[D]
- If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
- Consider tramadol only if acute rescue therapy is needed (see the first recommendation in the section, Treatments That Should Not Be Used, about long-term use).
- Consider capsaicin cream[E] for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.
Treatments That Should Not Be Used
- Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so:
- cannabis sativa extract
- capsaicin patch
- tramadol (this is referring to long-term use; see the previous section for short-term use)
- sodium valproate (follow MHRA safety advice on sodium valproate).
- Offer carbamazepine as initial treatment for trigeminal neuralgia. Follow the MHRA safety advice on antiepileptic drugs in pregnancy.
- If initial treatment with carbamazepine is not effective, is not tolerated or is contraindicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.
[A] The World Health Organization ICF (International Classification of Functioning, Disability and Health, 2001) defines participation as ‘A person’s involvement in a life situation.’ It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.
[B] A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.
[C] In November 2013, duloxetine was licensed for diabetic peripheral neuropathic pain only, and gabapentin was licensed for peripheral neuropathic pain only, so use for other conditions was off label. See NICE's information on prescribing medicines.
[D] Pregabalin and gabapentin are Class C controlled substances (under the Misuse of Drugs Act 1971) and Schedule 3 under the Misuse of Drugs Regulations 2001. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019).
Follow the MHRA safety advice on pregabalin in pregnancy.
[E] In November 2013, capsaicin cream (Axsain) was licensed for post-herpetic neuralgia and painful diabetic peripheral polyneuropathy only, so use for other conditions was off-label. The SPC states that this should only be used for painful diabetic peripheral polyneuropathy ‘under the direct supervision of a hospital consultant who has access to specialist resources’. See NICE's information on prescribing medicines.