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Palliative cancer care - pain - Management
View full scenario
How should I manage neuropathic pain?
- Consider whether there is a treatable underlying cause (for example, nerve compression from bone metastases or soft-tissue disease) and seek specialist advice regarding further treatment of the cause (for example, surgical stabilization for bone metastases or radiotherapy for soft-tissue disease).
- If pain is purely neuropathic and reversible conditions (for example, vitamin B12 deficiency) have been excluded:
- Consider offering amitriptyline (off-label use) or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin).
- Titrate the dosage according to response and tolerability.
- For further information, on contraindications, cautions, managing adverse effects, and second-line options if amitriptyline or pregabalin are not effective, see the CKS topic on Neuropathic pain - drug treatment.
- If pain is of mixed origin, use standard analgesics in addition to a tricyclic antidepressant or pregabalin (or gabapentin) if pain is not adequately controlled with standard analgesia alone. For more information, see Persistent pain.
- Seek specialist advice or consider referral if pain persists.
In depth
Prescriptions
Amitriptyline (neuropathic pain): starting dose
Age from 18 years onwards
Amitriptyline: titrate up from 10mg daily until pain settles
Amitriptyline 10mg tablets
Take one tablet at night. If pain does not settle, gradually increase the dose by one tablet (10mg) at night depending on response and if tolerated. Do not take more 75mg daily unless instructed by your doctor.
Supply 28 tablets.
Pregabalin (neuropathic pain): starting dose
Age from 18 years onwards
Pregabalin: titrate up from 150mg daily until pain settles.
Pregabalin 75mg capsules
Take one capsule twice daily. If pain does not settle, increase the dose to two capsules (150mg) twice daily after 3 to 7 days, then if needed, to a maximum dose of four capsules (300mg) twice daily after an additional 7 days, depending on response and if tolerated.
Supply 56 Capsules.
Gabapentin (neuropathic pain): starting doses
Age from 18 years onwards
Gabapentin: fast titration from 300mg to 900mg a day over 3 days
Gabapentin 300mg capsules
Take one capsule on the first day, then take one capsule twice a day on the second day, then take one capsule three times a day on the third day. If tolerated, increase the total daily dose by one capsule (300mg) every 2 to 3 days until the pain settles. Once you have reached 6 capsules (1800mg) daily, see your doctor to review this medicine before increasing the dose further.
Supply 100 capsules.
Gabapentin: fast titration from 900mg on day 1 onwards
Gabapentin 300mg capsules
Take one capsule three times a day for 3 days, then increasing the total daily dose by one capsule (300mg) every two or three days depending on response and if tolerated. Once you have reached 6 capsules (1800mg) daily, see your doctor to review this medicine before increasing the dose further.
Supply 100 capsules.
Gabapentin: slower titration regimen
Gabapentin 100mg capsules
Take one capsule at night, increasing by one capsule daily depending on response and if tolerated. Once you have reached 12 capsules (1200mg) daily, see your doctor before increasing the dose further.
Supply 100 capsules.
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