Executive summary of the Clinical Guidelines of Pharmacotherapy for Neuropathic Pain: second edition by the Japanese Society of Pain Clinicians

Abstract

Neuropathic pain has a substantial effect on quality of life (QOL). The Japanese Society of Pain Clinicians (JSPC) has developed clinical guidelines of pharmacotherapy for neuropathic pain. These guidelines offer clarity on recommendations based on both the most recent scientific evidence and expert opinions. Understanding the concept, disease entity, and burden of neuropathic pain, as well as its screening and diagnosis are important steps before starting pharmacotherapy. As well as other guidelines, the guidelines propose several lines of pharmacotherapies in a step-wise manner. To name a few different points, our guidelines propose an extract from inflamed cutaneous tissue of rabbits inoculated with vaccinia virus, which has been found to be effective for post-herpetic neuralgia in Japan, as one of the second-line drugs. When prescribing opioid analgesics, proposed as the third-line drugs, for neuropathic pain, the guidelines recommend physicians continue evaluations on either abuse or addiction. The guidelines do not recommend concomitant use of nonsteroidal anti-inflammatory drugs and acetaminophen because of lack of clinical evidence of their efficacy. If patients do not respond well to pharmacotherapy, which is prescribed in a step-wise manner, other treatment strategies should be considered to improve patients’ activities of daily living and QOL.

A Comprehensive Algorithm for Management of Neuropathic Pain

“…The most commonly studied are duloxetine and venlafaxine. They facilitate descending inhibition by blocking serotonin and noradrenaline reuptake [3,9]. They have been shown to be effective in peripheral diabetic neuropathy, painful peripheral neuropathy [8,13], and more recently in central neuropathic pain secondary to multiple sclerosis [50].…”

“…However, venlafaxine is not effective in post-herpetic neuralgia [13]. Beyond neuropathic pain, SNRIs have been shown to be effective in osteoarthritis, chronic low back pain, fibromyalgia, and depression [3]. Systematic review of 14 RCTs, nine looking at duloxetine and five at venlafaxine, demonstrated a combined NNT of 6.4 (5.2–8.4) and an NNH of 11.8 (9.5–15.2) [2].…”

“…Neuropathic pain has a significant impact on patients’ quality of life, as well as social, economic, and psychological well-being [1]. Notably, it has an even larger economic burden on society as a whole when one considers the financial cost of managing it in the chronic setting [2,3]. Estimates of its prevalence in the general population vary from as little as 1% to as much as 7–8% [4,5]; however, when taking into account conditions such as diabetes (26%), herpes zoster/shingles (19%), and postsurgical pain (10%), the incidence is much higher [1].…”

<p>Mirogabalin in Japanese Patients with Renal Impairment and Pain Associated with Diabetic Peripheral Neuropathy or Post-Herpetic Neuralgia: A Phase III, Open-Label, 14-Week Study</p>

“…Neuropathic pain is a common clinical problem, affecting approximately 1 in 10 of the general population, and is associated with a number of underlying conditions, including diabetes mellitus, infection, surgery, and cancer. 1,2 The symptoms may include burning pain, sensations of pressure, electric shock, or stabbing pain, and mechanical allodynia. 3 Neuropathic pain causes intense distress for patients, and is commonly associated with depression, anxiety, and sleep disturbances.…”

“… 6 , 7 Current therapeutic recommendations include antidepressants (duloxetine), anticonvulsants (pregabalin, gabapentin), topical analgesics (lidocaine, capsaicin), and even opioids (tapentadol). 2 , 8 , 9 However, not all of these agents are approved for treatment by regulatory authorities; of those that are approved, optimal administration may be compromised by the occurrence of adverse events (AEs), and efficacy is limited. 10 , 11 Polypharmacy and off-label treatment is common, 12 but can be risky for patients, especially for the elderly, who may have additional comorbidities.…”