Guidelines for the Pharmacological Treatment of Peripheral Neuropathic Pain: Expert Panel Recommendations for the Middle East Region

Abstract

Neuropathic pain (NeP) has been the focus of extensive basic and clinical research over the past 20 years. This has led to an increased understanding of underlying pathophysiological mechanisms and the development of new therapeutic agents, as well as a clearer definition of the role of established medications. To date there are no published treatment guidelines for NeP in the Middle East. A multidisciplinary panel of Middle East and international experts met to review critically and reach a consensus on how best to apply evidence-based guidelines for the treatment of NeP (mainly peripheral NeP) in the Middle East. The expert panel recommended pregabalin, gabapentin and secondary amine tricyclic antidepressants (nortriptyline and desipramine) as first-line treatments for peripheral NeP. Serotonin-norepinephrine reuptake inhibitor antidepressants, tramadol and controlled-release opioid analgesics were recommended as second-line treatments. There is a need to increase diagnostic awareness of NeP, use validated screening questionnaires and undertake more treatment research in the Middle East region.

Clinical practice guidelines for management of neuropathic pain: Expert panel recommendations for South Africa

“…In the past few years, several national, regional and international guidelines, systematic reviews and expert panel recommendations have been published for the treatment of NeuP, [16][17][18][19]21,22,26,27,41 and for specific aetiologies; 20,23,24 these are summarised in Table 4a and 4b. The first-line treatments recommended by most of the guidelines are TCAs, α 2 δ-ligands or gabapentinoids (pregabalin and gabapentin), and topical lidocaine (for localised NeuP), with selective serotonin/ noradrenaline reuptake inhibitors (SNRIs) sometimes included as first-line, sometimes second-line therapy.…”

“…The IASP NeuPSIG guidelines 27 reviewed several high-quality RCTs that showed the efficacy of opioid analgesics including tramadol in patients with Compiled from Martinez et al, 16 Bohlega et al, 21 Dworkin et al, 27 and experts' clinical experience and opinion. SNRIs = serotonin-noradrenalin reuptake inhibitors; MOAIs = monoamine oxidase inhibitors; MDD = major depression disorder; GAD = generalised anxiety disorder; TCAs = tricyclic antidepressants; SSRIs = selective serotonin reuptake inhibitors.…”

“…TCAs are associated with cardiac toxicity and hence amitriptyline is contraindicated in patients who have ischaemic heart disease or an increased risk of sudden cardiac death. 77,78 The MER guidelines 21 recommend a screening ECG before beginning treatment with TCAs in patients over 40 years of age. Amitriptyline should be avoided in elderly patients.…”

“…A systematic review of evidence by Danish pain experts, 17 consensus recommendations from the Canadian Pain Society 19 and consensus recommendations from experts in Latin America, 18 the Middle-East region (MER) 21 and the Maghreb region 22 were also consulted. Reference was also made to the American Academy of Neurology (AAN) guidelines for management of painful diabetic peripheral neuropathy (DPN); 20 postherpetic neuralgia (PHN) 24 and trigeminal neuralgia (TN) 23 were also referred to.…”

“…Recommendations from recent international and regional guidelines were reviewed in addition to discussion of recent systematic reviews, meta-analyses, and peer-reviewed randomised, double-blind, placebo-controlled studies; [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] a number of Cochrane reviews were also referred to. [31][32][33][34][35][36][37][38][39][40] The validity, clinical relevance, and applicability of the evidence for peripheral and central NeuP in South Africa were discussed.…”