1. Newer guidelines for treatment of neuropathic pain
Gautam das

2. Treatment guidelines Also called clinical practice guidelines
Issued by professional or academic bodies
Systematically developed statements based on available evidence to help clinicians in making decision
High quality evidence may be lacking
Geographical variation should be there

3. What is neuropathic pain?
Nociceptive pain: Pain that arises from actual or threatened damage to non- neural tissue and is due to the activation of nociceptors.
Neuropathic pain: Pain caused by a lesion or disease of the somatosensory nervous system.

4. Features of neuropathic pain
Burning sensation
Tingling sensation, crawling of ant sensation
Change of temperature increase pain
Touch increases pain
Feeling of numbness in area of pain
Electric shock like pain
Little pressure increases pain
Radiation of pain

5. How to diagnose neuropathic pain? Bedside diagnosis:
Neuropathic Pain Questionnaire (NPQ)
ID Pain 
PainDETECT 
The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
Douleur Neuropathique en 4 Questions (DN4)

6. Investigations to diagnosis of neuropathic pain
Quantitative sensory testing (QST)
Quantitative Sudomotor Axon Reflex Testing (QSART)
Skin biopsy
NCS/ EMG

7. Outline of management Pharmacotherapy Non-pharmacological treatment
Interventional management

8. Pharmacological management
Antidepressants
Anticonvulsants
Na channel blockers
Capsaicin
Opioids
Canabinoids

9. interventions Intravenous therapies (Ketamine, Lidocaine)
Sympathetic blocks
Pulsed RF
Conventional RF
Spinal Cord Stimulation

10. systematic review OF Clinical practice guidelines for the management of neuropathic pain

12. All Neuropathic Pain (Excluding Trigeminal Neuralgia)

13. Step 1. Amitriptyline
Start at 10mg at night, increase by 10mg every 3-7 days according to effect & tolerability
Usual Therapeutic Dose Range: 25-75mg at night
There is limited evidence of effectiveness of doses >75mg (use only on the advice of pain services)

14. Amitriptyline cont.…
Duration of adequate trial: 6-8 weeks with at least 2 weeks at the maximum tolerated dose
Do not stop abruptly Reduce gradually over 4 weeks (or 6 months if taking long term)
Contraindicated in arrhythmias, severe liver disease, recent MI & manic phase of bipolar disorder.
Can be used in combination with gabapentin or pregabalin if there is a partial response to either or both medications.

15. Step 2: Gabapentin
Start at 300mg at night, titrate upwards until efficacy achieved or not tolerated. Reduced doses required in renal impairment.
The rate of increase should be guided by patient & tolerability.
Usual Therapeutic Dose Range: 300mg-3600mg daily in three divided doses
Duration of adequate trial: 3-8 weeks for titration plus 2 weeks at maximum tolerated dose.
Do not stop abruptly. Decrease gradually over 1-2 weeks

16. Step 3: Pregabalin
Start at 75mg twice daily, titrate upwards until efficacy achieved or not tolerated. Reduced doses required in renal impairment.
The rate of increase should be guided by patient & tolerability.
Usual Therapeutic Dose Range: mg daily in divided doses
Duration of adequate trial: 3-8 weeks for titration plus 2 weeks at maximum tolerated dose.
Do not stop abruptly. Decrease gradually over 1-2 weeks

17. Duloxetine (If diabetic neuropathy)
Avoid if CrCl <30ml/minute
Start at 60mg daily (a 30mg starting dose may be appropriate for some patients). Increase to 60mg twice daily after 1 week if needed.
Duration of adequate trial: 8 weeks with at least 4weeks at maximum tolerated dose.
Do not stop abruptly. Decrease dose gradually over 1-2 weeks
If the first choice is not tolerated or ineffective, discontinue and try the other drug

18. Treatment of Trigeminal Neuralgia

19. Carbamazepine 1st line
Start at 100mg twice daily (prescribe generically)
Titrate slowly e.g. by 100mg every 3 days to 1600mg in divided doses. (MR preparations may be useful at night if the person experiences breakthrough pain).
If there is inadequate response or treatment is not tolerated consider early referral to a specialist pain or condition specific service

20. Post- Herpetic Neuralgia
Treat initially with standard oral therapies as per steps 1-3 and topical capsaicin (unless contra-indicated or not tolerated).
If standard therapies fail, or lead to intolerable side effects, consider lidocaine 5% medicated plasters, these are approved for primary care initiation when used to treat post-herpetic neuralgia.

21. TOPICAL TREATMENTS
Consider capsaicin cream for patients with localized neuropathic pain who wish to avoid, or who cannot tolerate oral treatments.1
To minimise side-effects start at 0.025% pea size amount four times daily for 6-8 weeks & increase if tolerated to 0.075% four times daily.
Duration of adequate trial: Pain relief begins within the 1st week and increases with continuing use, over the next 2-8 weeks

22. Interventions in neuropathic pain
Robert H. Dworkin et al. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain. 2013; 154(11): 2249–2261.
Van zundert et al. Evidence based interventional pain practice according to clinical diagnosis. Pain practice. 2011; 11(5)

23. Herpes zoster
Epidural or paravertebral nerve block(s) for treatment of pain
Quality of Evidence: Moderate
Strength of Recommendation: Weak
Provides relief of acute pain, but has not been compared against less invasive treatments, such as oral pharmacotherapy

24. Wip recommendation

26. WIP Algorithm FOR DPN Diabetic polyneuropathy
Exclude other causes of neuropathy
Conventional medical management of diabetes
Optimal pharmacological management with (combination of) anti-neuropathic pain drugs
Consider spinal cord stimulation in treatment resistant cases (Recommendation: 2C+)

28. WIP algorithm for BRACHIAL PLEXUS INJURY
Painful brachial plexus lesion Rehabilitation ± pharmacological management Surgical reconstruction for nerve lesion Consider DREZ (dorsal root entry zone) lesion for severe persistent pain Consider spinal cord stimulation Motor cortex/ Brain stimulation (Recommendation: 0)

31. WIP RECOMMENDATION FOR RADICULOPATHY
Interlaminar corticosteroid injection
2B+/-
TF steroid injection in contained herniation
2B+
TF steroid injection in extruded herniation
2B-
RF lesioning at the level of the spinal DRG
2A-
PRF at DRG
2C+

33. WIP RECOMMENDATION FOR FBSS
Spinal Cord stimulation in FBSS
2A+
Adhesionolysis by epiduroscopy in FBSS
2B+

35. WIP RECOMMENDATION FOR CRPS
Intravenous Regional block with Guanethidine
2A-
Stellate ganglion block
2B+
Lumber Sympathetic block
Brachial plexus block
2C+
Epidural infusion analgesia
Spinal Cord Stimulation
Peripheral nerve Stimulation

37. WIP RECOMMENDATION FOR TRIGEMINAL NEURALGIA
Radiofrequency treatment of Gasserian ganglion (Conventional/Thermal)
2B+
Pulsed RF treatment Gasserian ganglion
2B-

38. summary Neuropathic pain is difficult to diagnose and treat
Pharmacotherapy is main form of treatment
Interventions have limited role, can be considered in refractory cases
Recent practice guidelines must be followed for both pharmacological and interventional treatment
We need Indian guidelines for our own population group