title: A pharmacological treatment algorithm for localized neuropathic pain.
abstract: Neuropathic pain is caused by a lesion or disease affecting the somatosensory system and is difficult to manage, often proving refractory to existing treatments. In more than half of cases, it is localized and affects a specific, clearly circumscribed area of the body (localized neuropathic pain, or LNP). A recently developed screening tool enables patients with probable neuropathic pain/LNP to be identified quickly and easily. In view of the conflicting current treatment recommendations, an advisory board of pain specialists met in June 2015 to develop a complementary treatment guidance algorithm, for use in the primary care setting and by non-pain specialists. The starting point of the algorithm is a diagnosis of LNP and there was consensus that first-line treatment should be a topical analgesic agent, because the benefit/risk ratios are far better than for systemic agents. Topical application offers site-specific delivery, a lower total systemic dose and avoidance of first-pass metabolism, reducing the risk of adverse events and drug/drug interactions. The 5% lidocaine medicated plaster has most evidence supporting its use in LNP, producing effective analgesia and reducing the associated area of allodynia, but other topical agents include capsaicin, clonidine and botulinum toxin type A. Treatment should be commenced with the topical agent of choice, and the patient re-assessed after an appropriate period. Where the response is good the topical agent is continued, with a re-evaluation after 3-6 months. A systemic agent (e.g. gabapentin, pregabalin, duloxetine, venlafaxine) is added if there is only a partial response, or substituted if there is no response, and the patient re-assessed after a month. If there is poor or no response to the systemic agent the patient should be switched to an alternative one and, if this also proves ineffective, referred to a pain specialist.
authors.affiliation: a a Pain Therapy Service, Azienda Ospedaliera Universitaria Parma Hospital , Parma , Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Allegri
authors.affiliation: b b Division of Neurological Pain Research and Therapy, Department of Neurology , Christian-Albrechts-Universität zu Kiel , Kiel , Germany.
authors.forename: Ralf
authors.initials: R
authors.lastname: Baron
authors.affiliation: c c Multidisciplinary Pain Centre, Antwerp University Hospital , Edegum , Belgium.
authors.forename: Guy
authors.initials: G
authors.lastname: Hans
authors.affiliation: d d Rehabilitation Department , Hospital del Trabajador de Asociación Chilena de Seguridad , Santiago , Chile.
authors.forename: Gerardo
authors.initials: G
authors.lastname: Correa-Illanes
authors.affiliation: e e Anaesthesiology Department , Hospital Universitario de Bellvitge, 08907 El Hospitalet de Llobregat , Barcelona , Spain.
authors.forename: Victor
authors.initials: V
authors.lastname: Mayoral Rojals
authors.affiliation: f f Centre for Pain Evaluation and Treatment, University Neurological Hospital , Lyons , France.
authors.forename: Gerard
authors.initials: G
authors.lastname: Mick
authors.affiliation: g g University Department of Anaesthesia , Pain Research Office, Gartnavel General Hospital , Glasgow , Scotland , UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Serpell
mesh_terms: D000465:Algorithms; D000700:Analgesics / Q000008:administration & dosage*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage; D009437:Neuralgia / Q000188:drug therapy*
chemical_list: D000700:Analgesics; D000779:Anesthetics, Local; D008012:Lidocaine
keywords: Algorithm; Analgesia; Benefit/risk ratio; Lidocaine medicated plaster; Localized neuropathic pain; Topical agent