Guidelines: Clinical practice guidelines for management of neuropathic pain

Neuropathic pain (NeuP) is challenging to diagnose and manage, despite ongoing improved understanding of the underlying mechanisms. Many patients do not respond satisfactorily to existing treatments. There are no published guidelines for diagnosis or management of NeuP in South Africa. A multidisciplinary expert panel critically reviewed available evidence to provide consensus recommendations for diagnosis and management of NeuP in South Africa. Following accurate diagnosis of NeuP, pregabalin, gabapentin, low-dose tricyclic antidepressants (e.g. amitriptyline) and serotonin norepinephrine reuptake inhibitors (duloxetine and venlafaxine) are all recommended as first-line options for the treatment of peripheral NeuP. If the response is insufficient after 2 4 weeks, the recommended next step is to switch to a different class, or combine different classes of agent. Opioids should be reserved for use later in the treatment pathway, if switching drugs and combination therapy fails. For central NeuP, pregabalin or amitriptyline are recommended as first-line agents. Companion treatments (cognitive behavioural therapy and physical therapy) should be administered as part of a multidisciplinary approach. Dorsal root entry zone rhizotomy (DREZ) is not recommended to treat NeuP. Given the large population of HIV/AIDS patients in South Africa, and the paucity of positive efficacy data for its management, research in the form of randomised controlled trials in painful HIV-associated sensory neuropathy (HIV-SN) must be prioritised in this country. © Medpharm Reprinted with permission from S Afr Med J 2012;102(5):312-325 Guidelines: Clinical practice guidelines for management of neuropathic pain 145 Vol 55 No 2 S Afr Fam Pract 2013 costs threefold higher than the costs for matched control populations.9 Reduced work ability of patients and carers, and medical expenses also contribute to the overall cost of NeuP.10 A survey in the USA revealed that almost 65% of working patients with painful diabetic neuropathy reported absence from work or decreased work productivity due to pain.11 Another study reported that the employment status was reduced, owing to pain, in 52% of patients with peripheral NeuP.7 In South Africa there are a number of specific challenges to evaluating and treating NeuP. Lack of education and awareness among physicians, including specialists, was noted as a problem in South Africa, leading to suboptimal identification, assessment and management of NeuP. For example, inappropriate use of non-steroidal antiinflammatory drugs (NSAIDs) and opioids as first-line treatment is widespread, and inappropriate back surgery is common. Referrals to pain clinicians often come too late, and even in specialist centres a multidisciplinary approach is not always taken. Patient access to care varies widely in South Africa, from rural to urban areas and across socioeconomic divides. But access to care does not guarantee access to the most appropriate drugs, as financial and supply-chain constraints, and restricted formulary in the public sector and restricted reimbursement in the private sector limit access to appropriate medications.12 Along with access issues, lack of trained personnel is also a problem.13,14 Added to these challenges, which are not necessarily unique to South Africa, is the high rate of HIV in this country and the paucity of evidence for treating painful HIV-related neuropathy.15 To improve NeuP management in South Africa, regional guidelines for NeuP management, which take local settings into account, are vital. The consensus recommendations described here aim to help healthcare practitioners in South Africa become more aware of NeuP, better skilled at its diagnosis, and equipped to select appropriate treatment options for patients suffering from NeuP.