Nice | Neuropathic pain

This guideline updates the advice on managing neuropathic pain. It's worth a look through as there are some changes. The main things are:

Diabetic neuropathy - now to be treated in the same way as other neuropathies

Do not use - Lidocaine, imipramine and nortriptyline don't have enough evidence behind them to be advised. This doesn't mean that they're not effective - nor that we can't use them!

Read on for a summary of the guidance...

Types of Neuropathy

The two big types are:

  • Central (eg after stroke, or with MS of spinal cord disorders)
  • Peripheral (eg diabetic neuropathy)

These should both be treated in the same way. I don't think that I was aware that central problems could cause pain in the same way that peripheral problems can.

Trigeminal Neuralgia

Carbemazepine should be used. If it can not be used, the patient should be referred.

Management of other Neuralgia

1st line  - any of

  • Amitripyline (not licensed)
  • Pregabalin
  • Gabapentin – only licensed for peripheral neuropathic pain
  • Duloxetine – only licensed for diabetic neuropathic pain

2nd line

  1. Try the others in turn

3rd line

  • Tramadol – for short term ‘rescue’ use only
  • Capsaicin cream – for localised pain if they can’t tolerate oral medications (licensed only for diabetic neuropathy / post-herpetic neuralgia)

Do not use the following (among others) without specialist advise to do so

  • Tramadol long term
  • Morphine
  • Capsaicin patch

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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