Pharmacologic management of neuropathic pain: evidence-based recommendations.
Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha2-delta ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research.
Dworkin
Robert H
RH
University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA University of Wisconsin, Madison, WI, USA University of Pennsylvania, Philadelphia, PA, USA Aarhus University Hospital, Aarhus, Denmark Helsinki University Central Hospital, Helsinki, Finland University of Washington, Seattle, WA, USA University of California, San Francisco, CA, USA University of Liverpool, Liverpool, United Kingdom Beth Israel Medical Center, New York, NY, USA Imperial College School, London, United Kingdom Oregon Health and Science University, Portland, OR, USA Johannes Gutenberg Universität, Mainz, Germany University of California, San Diego, CA, USA.
O'Connor
Alec B
AB
Backonja
Miroslav
M
Farrar
John T
JT
Finnerup
Nanna B
NB
Jensen
Troels S
TS
Kalso
Eija A
EA
Loeser
John D
JD
Miaskowski
Christine
C
Nurmikko
Turo J
TJ
Portenoy
Russell K
RK
Rice
Andrew S C
ASC
Stacey
Brett R
BR
Treede
Rolf-Detlef
RD
Turk
Dennis C
DC
Wallace
Mark S
MS
D000818:Animals; D019317:Evidence-Based Medicine / Q000379:methods* / Q000592:standards*; D006287:Health Planning Guidelines; D006801:Humans; D009437:Neuralgia / Q000188:drug therapy* / Q000378:metabolism / Q000503:physiopathology; D010146:Pain / Q000188:drug therapy / Q000378:metabolism / Q000503:physiopathology