An evidence-based algorithm for the treatment of neuropathic pain

Abstract

Objective: The purpose of this article is to discuss an evidence-based algorithm that can be implemented by the primary care physician in his/her daily clinical practice for the treatment of patients with neuropathic pain conditions.

Method: A treatment algorithm for neuropathic pain was formulated on the basis of a review of 105 high-quality, randomized, placebo-controlled clinical trials. The number needed to treat (NNT) and number needed to harm (NNH) were used to compare the safety and effectiveness of current treatments for neuropathic pain syndromes. Most of the clinical trials reviewed in the analysis assessed tricyclic antidepressants (TCAs) and antiepileptic drugs (AEDs).

Results: TCAs had the lowest NNT followed by opioids and AEDs, such as gabapentin and pregabalin. The nature of the retrospective calculation of the NNT and NNH involves obvious limitations because of the pooling of studies with different experimental designs and outcomes.

Conclusion: Patients presenting with neuropathic pain are becoming a more frequent occurrence for the primary care physician as the population ages. Evidence-based treatment options allow for the most efficient and effective pharmacotherapy regimen to be implemented.

Figure 1

Referral model for the care of chronic pain. Adapted with permission from the American Pain Society.^[21] PCP, primary care physician; OS, orthopedic surgeon; PT, physical therapist; PSY, psychotherapist; Pain, pain specialist; N, neurologist; PMR, physical medicine and rehabilitation specialist.

Figure 2

Proposed treatment algorithm for neuropathic pain. Adapted with permission Finnerup and colleagues.^[37] TCA, tricyclic antidepressants; SNRI, serotonin/noradrenaline reuptake inhibitors.