Hospitalist Clinical Practice Guidelines: 2018 Midyear Review

Neuropathic Pain Pharmacotherapy

Japanese Society of Pain Clinicians

First-line drugs

Pregabalin inhibits the release of excitatory neurotransmitters by combining with alpha-2-delta subunits of voltage-dependent calcium channels in the central nervous system. Similarly, gabapentin and gabapentin enacarbil work by combining with alpha-2-delta subunits.

The analgesic effect of serotonin-noradrenaline reuptake inhibitors (SNRIs) is considered to be mediated by activation of the descending pain inhibitory system. Duloxetine improves not only pain, but also quality of life in patients with peripheral neuropathy. In addition to duloxetine, two other SNRIs, venlafaxine and milnacipran, are available.

Second-line drugs

The extract from inflamed cutaneous tissue of rabbits inoculated with vaccinia virus (ERV) has been found to be effective, particularly for post-herpetic neuralgia.

Tramadol acts as both a mu-opioid receptor agonist and SNRI. It is categorized as an opioid analgesic [weak], which is not designated as a restricted opioid for medical use. The analgesic effects of tramadol have been demonstrated for painful diabetic polyneuropathy, postherpetic neuralgia, and cancer-related neuropathic pain.

Third-line drugs

Opioid analgesics are effective for a variety of diseases associated with peripheral and central neuropathic pain, including painful diabetic polyneuropathy and post-herpetic neuralgia.

There is abundant evidence for the analgesic efficacy of morphine and oxycodone. Transdermal fentanyl (both 1- and 3-day patches) has been approved for moderate-severe cancer pain when switching from other opioid analgesics. Buprenorphine hydrochloride is a partial agonist for mu-opioid receptors, showing equivalent efficacy.

Reference

• Sumitani M, Sakai T, Matsuda Y, et al. Executive summary of the Clinical Guidelines of Pharmacotherapy for Neuropathic Pain: second edition by the Japanese Society of Pain Clinicians. J Anesth. 2018 Jun;32(3):463-478. https://link.springer.com/article/10.1007%2Fs00540-018-2501-0

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Cite this: Hospitalist Clinical Practice Guidelines: 2018 Midyear Review - Medscape - Jul 03, 2018.