title: Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society.
abstract: BACKGROUND
  Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians.
  
  
  OBJECTIVE
  To review the randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence-based consensus statement on its management.
  
  
  METHODS
  RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) 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 and ease of use.
  
  
  RESULTS
  Analgesic agents recommended for first-line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled-release opioid analgesics are recommended as second-line treatments for moderate to severe pain. Cannabinoids are now recommended as third-line treatments. Recommended fourth-line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacosamide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions.
  
  
  CONCLUSIONS
  These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side-effect profile and drug accessibility, including cost. Additional studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics, long-term outcomes and treatment of pediatric, geriatric and central NeP.
authors.forename: Dwight
authors.initials: D
authors.lastname: Moulin
authors.forename: Aline
authors.initials: A
authors.lastname: Boulanger
authors.forename: A J
authors.initials: AJ
authors.lastname: Clark
authors.forename: Hance
authors.initials: H
authors.lastname: Clarke
authors.forename: Thuan
authors.initials: T
authors.lastname: Dao
authors.forename: G A
authors.initials: GA
authors.lastname: Finley
authors.forename: Andrea
authors.initials: A
authors.lastname: Furlan
authors.forename: Ian
authors.initials: I
authors.lastname: Gilron
authors.forename: Allan
authors.initials: A
authors.lastname: Gordon
authors.forename: Patricia K
authors.initials: PK
authors.lastname: Morley-Forster
authors.forename: Barry J
authors.initials: BJ
authors.lastname: Sessle
authors.forename: Pamela
authors.initials: P
authors.lastname: Squire
authors.forename: Jennifer
authors.initials: J
authors.lastname: Stinson
authors.forename: Paul
authors.initials: P
authors.lastname: Taenzer
authors.forename: Ana
authors.initials: A
authors.lastname: Velly
authors.forename: Mark A
authors.initials: MA
authors.lastname: Ware
authors.forename: Erica L
authors.initials: EL
authors.lastname: Weinberg
authors.forename: Owen D
authors.initials: OD
authors.lastname: Williamson
mesh_terms: D000700:Analgesics / Q000627:therapeutic use*; D002170:Canada; D059350:Chronic Pain / Q000188:drug therapy*; D006801:Humans; D009437:Neuralgia / Q000188:drug therapy*; D059408:Pain Management / Q000379:methods*
chemical_list: D000700:Analgesics