2013 NICE CG173 成人神经性疼痛药物管理指南
Neuropathic pain - pharmacological management: the pharmacological management of neuropathic pain in adults in non-specialist settings
2013-11-20
Pain is an unpleasant sensory and emotional experience that can have a significant impact on aperson's quality of life, general health, psychological health, and social and economic wellbeing.The International Association for the Study of Pain (IASP 2011) defines neuropathic pain as 'paincaused by a lesion or disease of the somatosensory nervous system'. Central neuropathic pain isdefined as 'pain caused by a lesion or disease of the central somatosensory nervous system',and peripheral neuropathic pain is defined as 'pain caused by a lesion or disease of theperipheral somatosensory nervous system'.Neuropathic pain is very challenging to manage because of the heterogeneity of its aetiologies,symptoms and underlying mechanisms (Beniczky et al. 2005). There is often uncertaintyregarding the nature and exact location of a lesion or health condition associated withneuropathic pain, particularly in non-specialist settings. Examples of common conditions thathave peripheral neuropathic pain as a symptom are painful diabetic neuropathy, post-herpeticneuralgia, trigeminal neuralgia, radicular pain, post-surgical chronic neuropathic pain, andneuropathic cancer pain (such as, chemotherapy-induced neuropathy, neuropathy secondary totumour antigens, or caused by direct invasion or compression of neural structures). Examples ofconditions that can cause central neuropathic pain include stroke, spinal cord injury and multiplesclerosis. Neuropathic pain can be intermittent or constant, and spontaneous or provoked.Typical descriptions of the pain include terms such as shooting, stabbing, like an electric shock,burning, tingling, tight, numb, prickling, itching and a sensation of pins and needles. People mayalso describe symptoms of allodynia (pain caused by a stimulus that does not normally provokepain), hyperalgesia (an increased response to a stimulus that is normally painful), anaesthesiadolorosa (pain felt in an anaesthetic [numb] area or region), and sensory gain or loss (IASP2011).A review of the epidemiology of chronic pain found that there is still no accurate estimateavailable for the population prevalence of neuropathic pain (Smith et al. 2012). For example, theprevalence of neuropathic pain overall has been estimated to be between 6% and 8%, frompostal surveys in France (Bouhassira 2008) and the UK (Torrance 2006). However, theseestimates came from studies using different questionnaires. Other condition-specific studieshave also mirrored the heterogeneous nature of neuropathic pain. For example, painful diabeticneuropathy is estimated to affect between 16% and 26% of people with diabetes (Jensen et al.2006; Ziegler 2008). Prevalence estimates for post-herpetic neuralgia range from 8% to 19% ofpeople with herpes zoster when defined as pain at 1 month after rash onset, and 8% whendefined as pain at 3 months after rash onset (Schmader 2002).The development of chronic pain after surgery is also fairly common, with estimates ofprevalence ranging from 10% to 50% after many common operations (Shipton 2008). This painis severe in between 2% and 10% of this subgroup of patients, and many of the clinical featuresclosely resemble those of neuropathic pain (Jung et al. 2004; Mikkelsen et al. 2004; Kehlet et al.2006). Furthermore, a study of 362,693 computerised records in primary care from theNetherlands estimated the annual incidence of neuropathic pain in the general population to bealmost 1% (Dieleman et al. 2008). This considerable variability in estimates of the prevalenceand incidence of neuropathic pain and similar conditions from general population studies is likelyto be because of differences in the definitions of neuropathic pain, methods of assessment andpatient selection (Smith and Torrance 2010, Smith et al. 2012).A number of pharmacological treatments can be used to manage neuropathic pain outside ofspecialist pain management services. However, there is considerable variation in how treatmentis initiated, the dosages used and the order in which drugs are introduced, whether therapeuticdoses are achieved and whether there is correct sequencing of therapeutic classes. A furtherissue is that a number of commonly used treatments are unlicensed for treating neuropathicpain, which may limit their use. These factors may lead to inadequate pain control, withconsiderable morbidity. Commonly used pharmacological treatments include antidepressants (tricyclic antidepressants[TCAs], selective serotonin reuptake inhibitors [SSRIs] and serotonin–norepinephrine reuptakeinhibitors [SNRIs]), antiepileptic (anticonvulsant) drugs, topical treatments and opioid analgesics.In addition to their potential benefits, all of these drug classes are associated with variousadverse effects.This short clinical guideline aims to improve the care of adults with neuropathic pain by makingevidence-based recommendations on the pharmacological management of neuropathic painoutside of specialist pain management services. A further aim is to ensure that people whorequire specialist assessment and interventions are referred appropriately and in a timely fashionto a specialist pain management service and/or other condition-specific services.
