Pharmacologic management of neuropathic pain: evidence-based recommendations

Robert Dworkin, Alec O Connor, Miroslav Backonja, John Farrar, Nanna Finnerup, Troels Jensen, Eija Kalso, John Loeser, Christine Miaskowski, Timo Nurmikko, Russell Portenoy, Andrew Rice, Brett Stacey, Rolf-Detlef Treede, Dennis Turk, Mark Wallace

    Research output: Contribution to journalArticleScientificpeer-review

    Abstract

    Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha 2-6 ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research. (c) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
    Original languageEnglish
    JournalPain
    Volume132
    Issue number3
    Pages (from-to)237-251
    Number of pages15
    ISSN0304-3959
    DOIs
    Publication statusPublished - 2007
    MoE publication typeA1 Journal article-refereed

    Cite this

    Dworkin, R., O Connor, A., Backonja, M., Farrar, J., Finnerup, N., Jensen, T., ... Wallace, M. (2007). Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain, 132(3), 237-251. https://doi.org/10.1016/j.pain.2007.08.033
    Dworkin, Robert ; O Connor, Alec ; Backonja, Miroslav ; Farrar, John ; Finnerup, Nanna ; Jensen, Troels ; Kalso, Eija ; Loeser, John ; Miaskowski, Christine ; Nurmikko, Timo ; Portenoy, Russell ; Rice, Andrew ; Stacey, Brett ; Treede, Rolf-Detlef ; Turk, Dennis ; Wallace, Mark. / Pharmacologic management of neuropathic pain : evidence-based recommendations. In: Pain. 2007 ; Vol. 132, No. 3. pp. 237-251.
    @article{98e23dd928ff4f82bad69cabfe86fd2e,
    title = "Pharmacologic management of neuropathic pain: evidence-based recommendations",
    abstract = "Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha 2-6 ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research. (c) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.",
    author = "Robert Dworkin and {O Connor}, Alec and Miroslav Backonja and John Farrar and Nanna Finnerup and Troels Jensen and Eija Kalso and John Loeser and Christine Miaskowski and Timo Nurmikko and Russell Portenoy and Andrew Rice and Brett Stacey and Rolf-Detlef Treede and Dennis Turk and Mark Wallace",
    year = "2007",
    doi = "10.1016/j.pain.2007.08.033",
    language = "English",
    volume = "132",
    pages = "237--251",
    journal = "Pain",
    issn = "0304-3959",
    publisher = "Lippincott williams & wilkins",
    number = "3",

    }

    Dworkin, R, O Connor, A, Backonja, M, Farrar, J, Finnerup, N, Jensen, T, Kalso, E, Loeser, J, Miaskowski, C, Nurmikko, T, Portenoy, R, Rice, A, Stacey, B, Treede, R-D, Turk, D & Wallace, M 2007, 'Pharmacologic management of neuropathic pain: evidence-based recommendations', Pain, vol. 132, no. 3, pp. 237-251. https://doi.org/10.1016/j.pain.2007.08.033

    Pharmacologic management of neuropathic pain : evidence-based recommendations. / Dworkin, Robert; O Connor, Alec; Backonja, Miroslav; Farrar, John; Finnerup, Nanna; Jensen, Troels; Kalso, Eija; Loeser, John; Miaskowski, Christine; Nurmikko, Timo; Portenoy, Russell; Rice, Andrew; Stacey, Brett; Treede, Rolf-Detlef; Turk, Dennis; Wallace, Mark.

    In: Pain, Vol. 132, No. 3, 2007, p. 237-251.

    Research output: Contribution to journalArticleScientificpeer-review

    TY - JOUR

    T1 - Pharmacologic management of neuropathic pain

    T2 - evidence-based recommendations

    AU - Dworkin, Robert

    AU - O Connor, Alec

    AU - Backonja, Miroslav

    AU - Farrar, John

    AU - Finnerup, Nanna

    AU - Jensen, Troels

    AU - Kalso, Eija

    AU - Loeser, John

    AU - Miaskowski, Christine

    AU - Nurmikko, Timo

    AU - Portenoy, Russell

    AU - Rice, Andrew

    AU - Stacey, Brett

    AU - Treede, Rolf-Detlef

    AU - Turk, Dennis

    AU - Wallace, Mark

    PY - 2007

    Y1 - 2007

    N2 - Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha 2-6 ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research. (c) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

    AB - Patients with neuropathic pain (NP) are challenging to manage and evidence-based clinical recommendations for pharmacologic management are needed. Systematic literature reviews, randomized clinical trials, and existing guidelines were evaluated at a consensus meeting. Medications were considered for recommendation if their efficacy was supported by at least one methodologically-sound, randomized clinical trial (RCT) demonstrating superiority to placebo or a relevant comparison treatment. Recommendations were based on the amount and consistency of evidence, degree of efficacy, safety, and clinical experience of the authors. Available RCTs typically evaluated chronic NP of moderate to severe intensity. Recommended first-line treatments include certain antidepressants (i.e., tricyclic antidepressants and dual reuptake inhibitors of both serotonin and norepinephrine), calcium channel alpha 2-6 ligands (i.e., gabapentin and pregabalin), and topical lidocaine. Opioid analgesics and tramadol are recommended as generally second-line treatments that can be considered for first-line use in select clinical circumstances. Other medications that would generally be used as third-line treatments but that could also be used as second-line treatments in some circumstances include certain antiepileptic and antidepressant medications, mexiletine, N-methyl-D-aspartate receptor antagonists, and topical capsaicin. Medication selection should be individualized, considering side effects, potential beneficial or deleterious effects on comorbidities, and whether prompt onset of pain relief is necessary. To date, no medications have demonstrated efficacy in lumbosacral radiculopathy, which is probably the most common type of NP. Long-term studies, head-to-head comparisons between medications, studies involving combinations of medications, and RCTs examining treatment of central NP are lacking and should be a priority for future research. (c) 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

    U2 - 10.1016/j.pain.2007.08.033

    DO - 10.1016/j.pain.2007.08.033

    M3 - Article

    VL - 132

    SP - 237

    EP - 251

    JO - Pain

    JF - Pain

    SN - 0304-3959

    IS - 3

    ER -

    Dworkin R, O Connor A, Backonja M, Farrar J, Finnerup N, Jensen T et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237-251. https://doi.org/10.1016/j.pain.2007.08.033