Treatment of Neuropathic Pain (not including trigeminal neuralgia)

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Consider early specialist

referral if:
there is diagnostic
uncertainty
patient has severe pain
pain significantly limits
daily activities
the underlying health
condition has
deteriorated

First, consider diagnosis. Enquire

about symptoms, examine and use
assessment tools.

General Pain Treatment guidance.

Patient information at www.glospain.nhs.uk
Paracetamol
Non-drug therapies

Continue to work
through neuropathic flow
chart whilst waiting

1st Line: Antidepressants. Start low and go slow

Amitriptyline
If adverse side effects, consider: Nortriptyline
Consider Duloxetine for Painful Diabetic Neuropathy

Suboptimal response after 8 weeks

2nd line: Antiepileptics. Start low and go slow

Add

General Principles
Regular clinical review

No response after 8 weeks

Stop antidepressant
Start antiepileptic

Gabapentin
(increase dose to a point where patient gains good clinical
effect 8 week trial period)
Suboptimal response or ineffective
For patients with
localised neuropathic
pain who cannot tolerate
oral treatments consider:
Capsaicin cream
(Axsain)

rd

3 line: Duloxetine (+ / - gabapentin)

Suboptimal response or ineffective

th

4 Line: Pregabalin (twice daily)

Suboptimal response or ineffective

Referral to specialist pain service

While awaiting specialist assessment consider
adding or substituting tramadol (for acute use only)

Is there peripheral localised neuropathic pain?

Secondary Care initiation only:

Yes
th

5 Line: Opioids Secondary care assessment and advice

(ensure regular paracetamol is also prescribed)
First - Codeine / Dihydrocodeine / Tramadol
If ineffective consider:
Second - Morphine (Zomorph)
Third - Oxycodone (Longtec)
Fourth - Tapentadol (Palexia SR)

Consider trial of topical

Lidocaine patches
(Versatis)
or
Capsacin 8% patches
(Qutenza) (secondary
care use only)