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[Non-Text] الطبيه Ministry of Health الاداره العامه للرعايه الصيدليه NEUROPATHIC PAIN 1 صفحه [Non-Text] الطبيه Ministry of Health الاداره العامه للرعايه الصيدليه Disclaimer The information in the guide is meant to help decide on the treatment approach to each patient individually. Therefore, the professional's advice is to take full responsibility of their safety and know their limits. Before treating your patient using this guideline be sure that your patient is well diagnosed and has been treated before. Every professional should take full responsibility for the safety of their patient. This guide reflects opinions synthesized from an organized group of experts into a written document. It should reflect the expert views of the treatment of the disease. The team of professional experts reviewed the guidelines and discussed it with the panel of individuals who are well versed on the topic of interest while carefully examining and discussing the scientific data available. This guideline has been designed to provide a practical and accessible guidance for health care practitioners. It is the responsibility of treating physicians to decide what is suitable for their patients. Therefore, the guidelines are not a substitute for the attending doctor's clinical judgment 2 صفحه [Non-Text] الطبيه Ministry of Health الاداره العامه للرعايه الصيدليه Introduction MEDICATIONS: (Use multi-modal analgesia)(Refer to table 3 for appropriate doses depending on pain severity) patient should not be on the following medication in order to start neuropathic pain treatment □ cannabis sativa extract □ capsaicin patch □ lacosamide □ lamotrigine □ levetiracetam □ morphine □ oxcarbazepine □ topiramate □ Patient should not be on Hydroxyurea □ Analgesia to be administered within 30 minutes of presentation Key points: • Chronic neuropathic pain is associated with poor quality of life. - Common peripheral neuropathies include painful diabetic neuropathy, HIV-associated neuropathy, chemotherapy-induced neuropathy, postherpetic neuralgia and trigeminal neuralgia. - Guidelines from different countries offer consistent recommendations for treating neuropathic pain. Effective first and second-line therapies include tricyclic antidepressants, duloxetine, venlafaxine, gabapentin, pregabalin and topical lidocaine. - Limitations to treatment include incomplete pain relief and medication side-effect profiles. - Future research considerations include the use of validated screening tools, multi-modal medication combinations and phenotypic subtyping. <table><tr><td>Medication</td><td rowspan="2">Dose Initial</td><td rowspan="2">Effective</td></tr><tr><td>Calcium channel α2-delta ligands</td></tr><tr><td>Pregabalin</td><td>150mg/day, given in either two or three divided doses</td><td>300–600mg/day</td></tr><tr><td></td><td>Dose may be increased to 300mg/day after an interval of three to seven days</td><td></td></tr><tr><td>Gabapentin</td><td>Day 1 – 300mg once daily</td><td>- Immediate release: 100 to 300 mg 1 to 3 times daily increase dose to a target dose range of 300 mg to 1.2 g 3 times daily.</td></tr></table> 3 صفحه 3 [Non-Text] السلامه Ministry of Health الاداره العامه للرعايه الصيدليه <table><tr><td></td><td></td><td>- Extended release: 300 mg at bedtime; increase dose to a target dose of 900 mg to 3.6 g once daily.</td></tr><tr><td></td><td>Day 2 — 300mg twice daily</td><td>900–3,600mg/day</td></tr><tr><td></td><td>Day 3 — 300mg three times daily</td><td></td></tr><tr><td colspan="3">Antidepressants – TCA * Contraindication if Severe liver impairment; acute heart failure</td></tr><tr><td>Amitriptyline</td><td>10–25mg/day</td><td>25–75mg/day</td></tr><tr><td></td><td>Dose can be increased 10–25mg every three to seven days as tolerated</td><td>Doses above 100mg should be used with caution</td></tr><tr><td></td><td>10–25mg/day</td><td></td></tr><tr><td colspan="3">Antidepressant – SNRI</td></tr><tr><td>Duloxetine</td><td>20–30mg/day</td><td>60–120mg/day in divided doses</td></tr><tr><td></td><td>or</td><td></td></tr><tr><td></td><td>60mg/day titrate up to 60mg twice a day</td><td></td></tr><tr><td colspan="3">*Contraindication if Use (MAOI) intended to treat psychiatric disorders (concurrently or within 14 days of discontinuing the MAO inhibitor); initiation of MAO inhibitor intended to treat psychiatric disorders within 5 days of discontinuing duloxetine; initiation of duloxetine in a patient receiving linezolid or intravenous methylene blue. Hepatic impairment; severe renal impairment or end-stage renal disease (ESRD); uncontrolled narrow-angle glaucoma; concomitant use with thioridazine or with potent CYP1A2 inhibitors.</td></tr><tr><td colspan="3">Topical/local treatment</td></tr><tr><td>Lidocaine5% plaster</td><td>One to three patches for up to 12 hours applied to the painful area in a 24-hour period***WE HAVE GEL</td><td>One to three patches for up to 12 hours applied to the painful area in a 24-hour period</td></tr><tr><td>Capsaicin 8%</td><td>One to four patches applied to the painful area, repeat every three monthsNOT AVAILABLE</td><td>One to four patches applied to the painful area, repeat every three months</td></tr><tr><td colspan="3">Opioids</td></tr><tr><td>Tramadol</td><td>50mg/daily; increase weekly by 50mg/day</td><td>-Immediate release: 25 to 50 mg every 6 hours as needed. The dose may be increased as needed and tolerated to 50 to 100 mg</td></tr></table> 4 صفحه 4 [Non-Text] السلامه Ministry of Health الاداره العامه للرعايه الصيدليه <table><tr><td></td><td>every 4 to 6 hours (max: 400 mg/day).-Extended release: 100 mg once daily; titrate by 100 mg/day increments every 5 days as needed (maximum: 300 mg/day)</td></tr></table> - Consider Tramadol ONLY if Acute rescue therapy needed. *Contraindication if Severe renal impairment, severe hepatic impairment, status asthmatics, chronic obstructive airway, acute or severe bronchial asthma, acute respiratory depression, hypercapnia, delirium tremens, seizure disorder, severe CNS depression, increased cerebrospinal or intracranial pressure, head injury, suspected surgical abdomen, acute intoxication with ethanol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs; breastfeeding, pregnancy; use during labor and delivery. pediatric patients <12 years; postoperative management in pediatric patients <18 years who have undergone tonsillectomy and/or adenoidectomy, GI obstruction (known or suspected); concomitant use with or within 14 days following MAO inhibitor therapy. - Treatment may be repeated ≥3 months as needed for return of pain (do not apply more frequently than every 3 months). • Area should be pretreated with a topical anesthetic prior to patch application. - Consider Capsaicin cream/patches with people with localized neuropathic pain who wish to avoid oral treatment. • DO NOT use in combination with external heat source (eg, heating pad). 5 صفحه [Non-Text] الطبيه Ministry of Health الاداره العامه للرعايه الصيدليه Figure: Pain Rating Scale: Use the following scale for pain assessment: • 1 – 3 Mild • 4 – 6 Moderate • 7 – 10 Severe 0 - 10 Numeric Pain Intensity Scale Signature Date Physician Name 6 صفحه