NICE guidance - diabetic neuropathy

• NICE suggest that (1,3):
  • for treatment of all neuropathic pain (except trigeminal neuralgia)
    • offer a choice of amitriptyline, duloxetine as initial treatment for neuropathic pain
      
      
    • if the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated
      
      
    • consider tramadol only if acute rescue therapy is needed
      
      
    • consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments
    • when withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

In this guidance (3) NICE state that antiepileptic drugs including gabapentinoids should not be initiated to manage chronic primary pain in people aged 16 years and over.

Reference:

• (1) NICE (April 2018). Neuropathic pain (adults) - pharmacological management
• (2) NICE (May 2008).Type 2 Diabetes Update
• (3) NICE (April 7th 2021). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain