7. Likely causes of neuropathy according to speed of onset Acute onset Inflammatory Immunological Toxic Vascular Subacute onset over weeks or months Toxic Nutritional Systemic disease Chronic onset over many years Hereditary Metabolic disease
9. Goals of Neuropathic Pain Management Treat/prevent recurrence of pain-causing condition Reduce pain Improve physical/psychologic function Improve quality of life
10. Neuropathic Pain: Approach to Treatment Diagnosis Treat underlying condition/symptomatic treatment Reduce Pain Prevention (if applicable) Reduce psychological distress Improve physical functioning Improve overall quality of life
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13. Risk Continuum of Pain Therapy Level of Risk Most invasive Least invasive Interventional techniques Oral medications Topical medications Psychologic/ physical approaches Injections
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17. Pharmacological Treatments *: FDA approved in various neuropathic pain diseas +: FDA approved for use in severe chrnic pain
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19. APPROACHES TO THE MANAGEMENT OF NEUROPATHIC PAIN Monotherapy Combinations Additional Measures B. Second-line Capsaicin Physiotherapy Lidocaine patch Occupational therapy Tizanidine Paracetamol Clonidine TENS Baclofen Acupuncture Alternative antidepressant (e.g. duloxetine) Opioid tramadol, morphine, oxycodone Opioid with TCA or AE
20. APPROACHES TO THE MANAGEMENT OF NEUROPATHIC PAIN Monotherapy Combinations C. Third-line Alternative opioids Ketamine plus opioid Ketamine Intrathecal drug delivery Neuromodulation Additional Measures : Paracetamol, TENS, Acupuncture,Physiotherapy, Occupational therapy plus Psychological support
21. Peripheral neuropathic pain ALGORITHM FOR SEQUENCE OF DIFFERENT DRUG TREATMENTS IN PERIPHERAL NEUROPATHIC PAIN Lidocaine patch NO Post-herpetic neuralgia and focal neuropathy Pregabalin/ Gabapentin Tramadol, oxycodone TCA (SNRI) TCA (SNRI) Pregabalin/ Gabapentin YES YES NO YES NO TCA contraindication TCA contraindication
22. Algorithm for the management of neuropathic pain Consider nonpharmacologic treatments (e.g. physiotherapy, psychological interventions) and, in some cases, early referral for nerve blocks to facilitate rehabilitation (e.g., complex regional pain syndrome) First Step
23. Algorithm for the management of neuropathic pain If postherpetic neuralgia or focal neuropathy, initiate topical lidocaine treatment Ineffective, partial response or other diagnosis Second Step
24. Algorithm for the management of neuropathic pain Initiate first-line drug monotherapy (Pregabalin or Gabapentin OR TCA OR SNRI) Third Step
25. Algorithm for the management of neuropathic pain Switch to alternate first-line drug monotherapy (TCA or SNRI OR Gabapentin or Pregabalin) Ineffective or not tolerated/ TCA contraindication Partial treatment response Consider adding alternate first-line drug (TCA or SNRI OR gabapentin or pregabalin) Fourth Step
26. Algorithm for the management of neuropathic pain Initiate monotherapy with Tramadol or Oxycodone Ineffective or not tolerated Partial treatment response Consider adding Tramadol or Oxycodone Fifth Step
27. Algorithm for the management of neuropathic pain Refer patient to pain specialty clinic for consideration of third-line drugs, interventional treatments and pain rehabilitation programs Ineffective or not tolerated Sixth Step
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