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Pharmacologic management of neuropathic pain: Evidence-based recommendations

Dworkin, Robert H.a,*; O’Connor, Alec B.a; Backonja, Miroslavb; Farrar, John T.c; Finnerup, Nanna B.d; Jensen, Troels S.d; Kalso, Eija A.e; Loeser, John D.f; Miaskowski, Christineg; Nurmikko, Turo J.h; Portenoy, Russell K.i; Rice, Andrew S.C.j; Stacey, Brett R.k; Treede, Rolf-Detlefl; Turk, Dennis C.f; Wallace, Mark S.m

doi: 10.1016/j.pain.2007.08.033

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 α2-δ 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.

aUniversity of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA

bUniversity of Wisconsin, Madison, WI, USA

cUniversity of Pennsylvania, Philadelphia, PA, USA

dAarhus University Hospital, Aarhus, Denmark

eHelsinki University Central Hospital, Helsinki, Finland

fUniversity of Washington, Seattle, WA, USA

gUniversity of California, San Francisco, CA, USA

hUniversity of Liverpool, Liverpool, United Kingdom

iBeth Israel Medical Center, New York, NY, USA

jImperial College School, London, United Kingdom

kOregon Health and Science University, Portland, OR, USA

lJohannes Gutenberg Universität, Mainz, Germany

mUniversity of California, San Diego, CA, USA

*Corresponding author. Tel.: +1 585 275 3524; fax: +1 585 473 5007.


Submitted February 4, 2007; received in revised form August 21, 2007; accepted August 23, 2007.

© 2007 Lippincott Williams & Wilkins, Inc.
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