Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis.
Nanna B. Finnerup,Nadine Attal,Simon Haroutounian,Ewan D McNicol,Ralf Baron,Robert H. Dworkin,Ian Gilron,Maija Haanpää,Per Hansson,Per Hansson,Troels S. Jensen,Troels S. Jensen,Peter R. Kamerman,Karen Lund,Andrew Moore,Srinivasa N. Raja,Andrew S.C. Rice,Andrew S.C. Rice,Michael C. Rowbotham,Emily S. Sena,Emily S. Sena,Philip J. Siddall,Philip J. Siddall,Blair H. Smith,Mark S. Wallace +24 more
TLDR
The results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain and allow a strong recommendation for use and proposal as first-line treatment in neuropathicPain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin.Abstract:
Summary Background New drug treatments, clinical trials, and standards of quality for assessment of evidence justify an update of evidence-based recommendations for the pharmacological treatment of neuropathic pain. Using the Grading of Recommendations Assessment, Development, and E valuation (GRADE), we revised the Special Interest Group on Neuropathic Pain (NeuPSIG) recommendations for the pharmacotherapy of neuropathic pain based on the results of a systematic review and meta-analysis. Methods Between April, 2013, and January, 2014, NeuPSIG of the International Association for the Study of Pain did a systematic review and meta-analysis of randomised, double-blind studies of oral and topical pharmacotherapy for neuropathic pain, including studies published in peer-reviewed journals since January , 1966, and unpublished trials retrieved from ClinicalTrials.gov and websites of pharmaceutical companies. We used number needed to treat (NNT) for 50% pain relief as a primary measure and assessed publication bias; NNT was calculated with the fi xed-eff ects Mantel-Haenszel method. Findings 229 studies were included in the meta-analysis. Analysis of publication bias suggested a 10% overstatement of treatment eff ects. Studies published in peer-reviewed journals reported greater eff ects than did unpublished studies (r² 9·3%, p=0·009). T rial outcomes were generally modest: in particular, combined NNTs were 6·4 (95% CI 5·2–8·4) for serotonin-noradrenaline reuptake inhibitors, mainly including duloxetine (nine of 14 studies); 7·7 (6·5–9·4) for pregabalin; 7·2 (5·9–9·21) for gabapentin, including gabapentin extended release and enacarbil; and 10·6 (7·4–19·0) for capsaicin high-concentration patches. NNTs were lower for tricyclic antidepressants, strong opioids, tramadol, and botulinum toxin A, and undetermined for lidocaine patches. Based on GRADE, fi nal quality of evidence was moderate or high for all treatments apart from lidocaine patches; tolerability and safety, and values and preferences were higher for topical drugs; and cost was lower for tricyclic antidepressants and tramadol. These fi ndings permitted a strong recommendation for use and proposal as fi rst-line treatment in neuropathic pain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin; a weak recommendation for use and proposal as second line for lidocaine patches, capsaicin high-concentration patches, and tramadol; and a weak recommendation for use and proposal as third line for strong opioids and botulinum toxin A. Topical agents and botulinum toxin A are recommended for peripheral neuropathic pain only. Interpretation Our results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest effi cacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profi ling probably account for moderate trial outcomes and should be taken into account in future studies. Funding NeuPSIG of the International Association for the Study of Pain.read more
Citations
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Marieke H. J. van den Beuken-van Everdingen,Laura M.J. Hochstenbach,Elbert A.J. Joosten,Vivianne C. G. Tjan-Heijnen,Daisy J.A. Janssen +4 more
TL;DR: Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer and in the upcoming decade, the authors need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in Patients with cancer.
Journal ArticleDOI
Neuropathic pain: An updated grading system for research and clinical practice
Nanna B. Finnerup,Simon Haroutounian,Peter R. Kamerman,Ralf Baron,David L.H. Bennett,Didier Bouhassira,Giorgio Cruccu,Roy Freeman,Per Hansson,Turo Nurmikko,Srinivasa N. Raja,Andrew S.C. Rice,Andrew S.C. Rice,Jordi Serra,Blair H. Smith,Rolf-Detlef Treede,Troels S. Jensen +16 more
TL;DR: A revised grading system of possible, probable, and definite neuropathic pain from 2008 is presented with an adjusted order, better reflecting clinical practice, improvements in the specifications, and a word of caution that even the “definite” level of neuropathicPain does not always indicate causality.
References
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Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment
TL;DR: A better understanding of neuropathic pain and of the translation of pathophysiological mechanisms into sensory signs will lead to a more effective and specific mechanism-based treatment approach.
Journal ArticleDOI
Advances in Neuropathic Pain: Diagnosis, Mechanisms, and Treatment Recommendations
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TL;DR: In this article, the authors describe current approaches to the diagnosis and assessment of neuropathic pain and discuss the results of recent research on its pathophysiologic mechanisms, and provide specific recommendations for use of these medications.
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TL;DR: Important design and statistical issues of this process of combining study results that can be used to draw conclusions about therapeutic effectiveness or to plan new studies are reviewed.
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Nadine Attal,Giorgio Cruccu,Maija Haanpää,Per Hansson,Troels S. Jensen,Turo Nurmikko,Cristina Sampaio,Søren H. Sindrup,Philip J Wiffen +8 more
TL;DR: Evaluated trials provide level A evidence for the efficacy of tricyclic antidepressants, gabapentin, pregabalin and opioids, with a large number of class I trials, followed by topical lidocaine and the newer antidepressants venlafaxine and duloxetine.
Journal ArticleDOI
Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline
Dawn L. Hershman,Christina Lacchetti,Robert H. Dworkin,Ellen M. Lavoie Smith,Jonathan Bleeker,Guido Cavaletti,Cynthia Chauhan,Patrick Gavin,Antoinette Lavino,Maryam B. Lustberg,Judith A. Paice,Bryan P. Schneider,Mary Lou Smith,Thomas J. Smith,Shelby A. Terstriep,Nina D. Wagner-Johnston,Kate Bak,Charles L. Loprinzi +17 more
TL;DR: Although the CIPN trials are inconclusive regarding tricyclic antidepressants (such as nortriptyline), gabapentin, and a compounded topical gel containing baclofen, amitriptylines HCL, and ketamine, these agents may be offered on the basis of data supporting their utility in other neuropathic pain conditions given the limited other CIPn treatment options.