Prescribing changes for generalist care: Pregabalin, what do you think ?

[PPSN_JudyB]

PPSN is a registered stakeholder for this guidance which means we can respond to NICE including your views before Monday 10th October. The proposed change means that it will be more difficult for patients to be prescribed Pregabalin by a GP. The reason given for the proposed change is cost.

NICE guidance: neuropathic pain in non specialist settings

“Commonly used pharmacological treatments include antidepressants (tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs] and serotonin–norepinephrine reuptake inhibitors [SNRIs]), anti-epileptic (anticonvulsant) drugs (such as gabapentin, pregabalin and carbamazepine), topical treatments (such as capsaicin and lidocaine) and opioid analgesics. All of these drug classes are associated with disadvantages, as well as potential benefits. A further issue is that a number of commonly used treatments (such as amitriptyline) are unlicensed for treatment of neuropathic pain, which may limit their use by practitioners. There is also uncertainty about which drugs should be used initially (first-line treatment) for neuropathic pain, and the order (sequence) in which the drugs should be used.

If amitriptyline* results in satisfactory pain reduction as first-line treatment but the person cannot tolerate the adverse effects, consider oral imipramine* or nortriptyline* as an alternative.

If gabapentin results in satisfactory pain reduction as first-line treatment but the person has difficulty adhering to the dosage schedule or cannot tolerate the adverse effects, consider oral pregabalin as an alternative.

Second line treatment

If first-line treatment was with amitriptyline* (or imipramine* or nortriptyline*), switch to or combine with oral gabapentin (or pregabalin as an alternative if gabapentin is effective but the person has difficulty adhering to the dosage schedule or cannot tolerate the adverse effects).

If first-line treatment was with gabapentin (or pregabalin) switch to or combine with oral amitriptyline* (or imipramine* or nortriptyline* as an alternative if amitriptyline is effective but the person cannot tolerate the adverse effects).

Third-line treatment

1.1.15 If satisfactory pain reduction is not achieved with second-line treatment:

refer the person to a specialist pain service and/or a condition-specific service7 and

while waiting for referral:

consider oral tramadol as third-line treatment instead of or in combination8 with the second-line treatment (For dosages please see box 1 Drug dosages).

consider a topical lidocaine patch for treatment of localised pain for people who are unable to take oral medication because of medical conditions and/or disability.

7 A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.

8 The combination of tramadol with amitriptyline, nortriptyline, imipramine or duloxetine is associated with a low risk of serotonin syndrome (the features of which include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus).

Other treatments

1.1.16 Do not start treatment with a topical capsaicin 8% patch or with opioids (such as morphine or oxycodone) other than tramadol without an assessment by a specialist pain service or a condition-specific service7.

1.1.17 Pharmacological treatments other than those recommended in this guideline that are started by a specialist pain service or a condition-specific service7 may continue to be prescribed in non-specialist settings, with a multidisciplinary care plan, local shared care agreements and careful management of adverse effects.

[jacquieb Volunteer]

Hi

I know this doesn't answer your question but thought you all might like to know, if you don't already, that it is extremely difficult to get lidocaine patches on NHS prescription, not because of the cost, but because the trials on this particular medication is non-conclusive, like many other drugs. This query is now with the PMT for approval. Strange though how you can get lidocaine gell 5% on prescription!!!

The cost on a private prescription is from £87.00 upwards for a pack of 30. I tried one yesterday, burnt the hell out of my back and was in agony all last night with hot sweats thrown into the bargain!

I have already reached the delirium stage and that's not due to drug useage that's for sure. Frightening reading.

Pregabalin anyone?

[helenlegs11 Volunteer]

Personally I have had far fewer side effects with pregabalin than gabapentin. Gabapentin made me very stupid, especially initially and the more metabolised pregabalin is a better drug altogether for me, however everyone is different.

I was told I couldn't have pregabalin at least 3 times before I eventually did get it, so the NICE guidelines above are exactly what many GP's have been practising for some time, It is simply more formalised now.

Far enough really, if people can tolerate gabapentin and it works for them great, as long as they realise there IS an alternative and don't suffer any lasting side effects needlessly when pregabalin may suit them better.

The regime I have now pregabalin+cymbalta+ tramadol is working better than anything else I have tried. No miracle at all, but I wasn't expecting one.

[jacquieb Volunteer]

What mg of each drug do you take daily Helen?

Pregabalin was far better than Gapapentin for me. More tolerable and slightly better results, only slightly.

[helenlegs11 Volunteer]

I haven't been taking them for very long and am taking 150mg (50 x 3) at the moment, will up it and see how I go. That compares to 2400 mg of gabapentin daily. I did sleep better with gabapentin but was also dopey during the day and had difficulty remembering words.

The cymbalta I have just increased to 120mg (60 x 2)

and the tramadol from 100 - 300mg's. The higher dose would only be if I couldn't sleep because of pain and I have only done that once recently, probably when my grandchildren come to stay I will have to do that again: )

I would say that this combination makes me feel more calm and that helps to cope with the pain better. I did stop taking the pregabalin for just over a week because I came out in horrid spots UGH! but with teenage (Ha Ha) spot cream I have had two goes at them now and have noticed the difference both times.

When I woke in the morning without the pregabalin my pelvis felt so heavy I feel as if I am 'welded' to the bed, thankfully the pregabalin has made me feel lighter. Shame is; I'm not !