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).
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).
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.