Pharmacological Management Of Chronic Neuropathic Pain Consensus Statement And Guidelines From The C

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Pharmacological Management Of Chronic Neuropathic
Pain Consensus Statement And Guidelines From
The Canadian Pain Society
DE Moulin MD, AJ Clark MD, I Gilron MD MSc, MA
Ware MD, CPN Watson MD, BJ Sessle MDS PhD, T
Coderre PhD, PK Morley-Forster MD, J Stinson RN
PhD, A Boulanger MD, P Peng MBBS, GA Finley MD, P
Taenzer PhD, P Squire MD, Dion MD MSc, A Cholkan
CA, A Gilani MD, A Gordon MD, J Henry PhD, R
Jovey MD, M Lynch MD, A Mailis-Gagnon MD MSc, A
Panju MB ChB, GB Rollman PhD, A Velly DDS PhD
J. Pain Res. Manage. 1213-21, 2007
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Neuropathic Pain - Background

• Neuropathic pain is generated by disorders of the
  peripheral and central nervous system
• It can be particularly severe and disabling
• Prevalence estimates indicate that 2 - 3 of the
  population in the developed world suffer from
  neuropathic pain which suggests that up to one
  million Canadians have this disabling condition
• Evidence-based guidelines for the pharmacologic
  management of neuropathic pain are therefore
  urgently needed
• Such considerations led to this study to develop
  guidelines

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Approaches

• Randomized, controlled trials, systematic reviews
  and existing guidelines focusing on the
  pharmacological management of neuropathic pain
  were evaluated and presented at a consensus
  meeting
• The authors used this information to recommend
  medications in the guidelines if their analgesic
  efficacy was supported by at least one
  methodologically sound randomized controlled
  trial showing significant benefit relative to
  placebo or another relevant control group
• Recommendations for treatment were based on the
  degree of evidence of analgesic efficacy, safety,
  ease of use and cost-effectiveness

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Recommendations

• First-line treatments are certain antidepressants
  (tricyclics) and anticonvulsants (gabapentin and
  pregabalin)
• Second-line treatments are serotonin/noradrenaline
  reuptake inhibitors and topical lidocaine
• Third-line treatments are Tramadol and
  controlled-release opioid analgesics
• Fourth-line treatments include cannabinoids,
  methadone and anticonvulsants with lesser
  evidence of efficacy, such as lamotrigine,
  topiramate and valproic acid
• Treatment must be individualized for each patient
  based on efficacy, side-effect profile and drug
  accessibility including cost
• The following slides summarize the treatment
  algorithm and the analgesic agents that may be
  considered for managing neuropathic pain

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TCA Gabapentin or Pregabalin
1st
Add additional agents sequentially if partial but
inadequate pain relief
SNRI Topical Lidocaine
2nd
3rd
Tramadol or CR Opioid Analgesic
Fourth Line Agents
5 gel or cream - useful for focal neuropathy
such as postherpetic neuralgia. Lidocaine patch
not available in Canada. e.g. Cannabinoids,
methadone, lamotrigine, topiramate, valproic
acid. Do not add SNRI to TCA SNRI
serotonin/noradrenaline reuptake inhibitor TCA
tricyclic antidepressant CR controlled-release



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Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
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Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
8
Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
9
Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
10
Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
11
Analgesic Agents for Managementof Neuropathic
Pain
Doses are based on clinical experience and may
deviate from those recommended in the product
monograph.
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Final Comment

• Further studies are required to examine
• head-to-head comparisons between
• analgesics, combinations of analgesics,
• long-term outcomes and treatment of
• pediatric and central neuropathic pain