Abstract
BackgroundPatients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain (NeP). This refractory chronic pain causes psychological distress and impacts patient quality of life. Published literature for treatment in refractory patients is sparse and often published as conference abstracts only. The aim of this study was to identify published data for three pharmacological treatments: pregabalin, lidocaine plaster, and duloxetine, which are typically used at 2nd line or later in UK patients with neuropathic pain.MethodsA systematic review of the literature databases MEDLINE, EMBASE and CCTR was carried out and supplemented with extensive conference and grey literature searching. Studies of any design (except single patient case studies) that enrolled adult patients with refractory NeP were included in the review and qualitatively assessed.ResultsSeventeen studies were included in the review: nine of pregabalin, seven of the lidocaine plaster, and one of duloxetine. No head-to-head studies of these treatments were identified. Only six studies included treatments within UK licensed indications and dose ranges. Reported efficacy outcomes were not consistent between studies. Pain scores were most commonly assessed in studies including pregabalin; trials of pregabalin and the lidocaine plaster reported the proportion of responders. Significant improvements in the total, sensory and affective scores of the Short-form McGill Pain Questionnaire, and in function interference, sleep interference and pain associated distress, were associated with pregabalin treatment; limited or no quality of life data were available for the other two interventions. Limitations to the review are the small number of included studies, which are generally small, of poor quality and heterogeneous in patient population and study design.ConclusionsLittle evidence is available relevant to the treatment of refractory neuropathic pain despite the clinical need. There is a notable lack of high-quality comparative studies. It is evident that there is a need for future, high quality trials, particularly "gold-standard" RCTs in this refractory patient population.
Highlights
Patients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain (NeP)
The aims of this review were: a) to identify the evidence base in refractory neuropathic pain for three pharmacological treatments which are typically used at 2nd line or later in UK patients with neuropathic pain, and b) to determine the efficacy, safety and tolerability of these drugs in this refractory patient population
Trial Flow Of the 4789 references retrieved from the literature databases, and 244 references retrieved from the hand searching, 21 publications met the inclusion criteria (Figure 1)
Summary
Patients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain (NeP). This refractory chronic pain causes psychological distress and impacts patient quality of life. Patients experience pain described most frequently as burning, tingling or electric shock [2] It is generally persistent and/or chronic in nature and can be further categorised as either peripheral or central depending on the origin of the lesion or dysfunction [1,3,4]. The prevalence of NeP is expected to rise due to population aging and the increased longevity of patients with cancer, HIV-infection, diabetes and other diseases [5]
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