Pharmacologic management of neuropathic pain: Evidence-based recommendations

Robert H. Dworkin, Alec B. O'Connor, Miroslav Backonja, John T. Farrar, Nanna B. Finnerup, Troels S. Jensen, Eija A. Kalso, John D. Loeser, Christine Miaskowski, Turo J. Nurmikko, Russell K. Portenoy, Andrew S C Rice, Brett R. Stacey, Rolf Detlef Treede, Dennis C. Turk, Mark S. Wallace

Research output: Contribution to journalArticle

1377 Citations (Scopus)

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 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.

Original languageEnglish (US)
Pages (from-to)237-251
Number of pages15
JournalPain
Volume132
Issue number3
DOIs
StatePublished - Dec 5 2007

Fingerprint

Neuralgia
Antidepressive Agents
Therapeutics
Randomized Controlled Trials
Mexiletine
Tramadol
Radiculopathy
Tricyclic Antidepressive Agents
Capsaicin
Calcium Channels
Lidocaine
Chronic Pain
Anticonvulsants
Opioid Analgesics
Comorbidity
Consensus
Placebos
Guidelines
Ligands
Safety

Keywords

  • Evidence-based recommendations
  • Neuropathic pain
  • Pharmacologic management
  • Randomized clinical trials

ASJC Scopus subject areas

  • Clinical Neurology
  • Psychiatry and Mental health
  • Neurology
  • Neuroscience(all)
  • Pharmacology
  • Clinical Psychology

Cite this

Dworkin, R. H., O'Connor, A. B., Backonja, M., Farrar, J. T., Finnerup, N. B., Jensen, T. S., ... Wallace, M. S. (2007). Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain, 132(3), 237-251. https://doi.org/10.1016/j.pain.2007.08.033

Pharmacologic management of neuropathic pain : Evidence-based recommendations. / Dworkin, Robert H.; O'Connor, Alec B.; Backonja, Miroslav; Farrar, John T.; Finnerup, Nanna B.; Jensen, Troels S.; Kalso, Eija A.; Loeser, John D.; Miaskowski, Christine; Nurmikko, Turo J.; Portenoy, Russell K.; Rice, Andrew S C; Stacey, Brett R.; Treede, Rolf Detlef; Turk, Dennis C.; Wallace, Mark S.

In: Pain, Vol. 132, No. 3, 05.12.2007, p. 237-251.

Research output: Contribution to journalArticle

Dworkin, RH, O'Connor, AB, Backonja, M, Farrar, JT, Finnerup, NB, Jensen, TS, Kalso, EA, Loeser, JD, Miaskowski, C, Nurmikko, TJ, Portenoy, RK, Rice, ASC, Stacey, BR, Treede, RD, Turk, DC & Wallace, MS 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
Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain. 2007 Dec 5;132(3):237-251. https://doi.org/10.1016/j.pain.2007.08.033
Dworkin, Robert H. ; O'Connor, Alec B. ; Backonja, Miroslav ; Farrar, John T. ; Finnerup, Nanna B. ; Jensen, Troels S. ; Kalso, Eija A. ; Loeser, John D. ; Miaskowski, Christine ; Nurmikko, Turo J. ; Portenoy, Russell K. ; Rice, Andrew S C ; Stacey, Brett R. ; Treede, Rolf Detlef ; Turk, Dennis C. ; Wallace, Mark S. / Pharmacologic management of neuropathic pain : Evidence-based recommendations. In: Pain. 2007 ; Vol. 132, No. 3. pp. 237-251.
@article{4a3a78fa3121445881f8d22ea8e3efbc,
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 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.",
keywords = "Evidence-based recommendations, Neuropathic pain, Pharmacologic management, Randomized clinical trials",
author = "Dworkin, {Robert H.} and O'Connor, {Alec B.} and Miroslav Backonja and Farrar, {John T.} and Finnerup, {Nanna B.} and Jensen, {Troels S.} and Kalso, {Eija A.} and Loeser, {John D.} and Christine Miaskowski and Nurmikko, {Turo J.} and Portenoy, {Russell K.} and Rice, {Andrew S C} and Stacey, {Brett R.} and Treede, {Rolf Detlef} and Turk, {Dennis C.} and Wallace, {Mark S.}",
year = "2007",
month = "12",
day = "5",
doi = "10.1016/j.pain.2007.08.033",
language = "English (US)",
volume = "132",
pages = "237--251",
journal = "Pain",
issn = "0304-3959",
publisher = "Elsevier",
number = "3",

}

TY - JOUR

T1 - Pharmacologic management of neuropathic pain

T2 - Evidence-based recommendations

AU - Dworkin, Robert H.

AU - O'Connor, Alec B.

AU - Backonja, Miroslav

AU - Farrar, John T.

AU - Finnerup, Nanna B.

AU - Jensen, Troels S.

AU - Kalso, Eija A.

AU - Loeser, John D.

AU - Miaskowski, Christine

AU - Nurmikko, Turo J.

AU - Portenoy, Russell K.

AU - Rice, Andrew S C

AU - Stacey, Brett R.

AU - Treede, Rolf Detlef

AU - Turk, Dennis C.

AU - Wallace, Mark S.

PY - 2007/12/5

Y1 - 2007/12/5

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 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.

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 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.

KW - Evidence-based recommendations

KW - Neuropathic pain

KW - Pharmacologic management

KW - Randomized clinical trials

UR - http://www.scopus.com/inward/record.url?scp=35748943212&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=35748943212&partnerID=8YFLogxK

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 -