Is treatment of postherpetic neuralgia in the community consistent with evidence-based recommendations?

Dworkin, Robert H.; Panarites, Christopher J.; Armstrong, Edward P.; Malone, Daniel C.; Pham, Sissi V.

doi:10.1016/j.pain.2012.01.015

Cited by 31 publications

(24 citation statements)

References 40 publications

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“…It has recently been reported that the drug treatment of postherpetic neuralgia by primary care physicians was roughly consistent with the US recommendations issued some years before. 6 In contrast, a recent large study of general practitioners’ adherence to current French recommendations observed a paucity of appropriate recall of first-line drugs. 8 One important educational objective of the present guidelines will be to facilitate their dissemination and subsequently assess their real life implementation in various countries.…”

Section: Discussionmentioning

confidence: 96%

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Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis

Finnerup

Attal

Haroutounian

et al. 2015

The Lancet Neurology

3,091

2,119

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Summary Background Neuropathic pain is difficult to treat. New treatments, clinical trials and standards of quality for assessing evidence justify an update of evidence-based recommendations for its pharmacological treatment. Methods The Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain conducted a systematic review of randomised double-blind studies of oral and topical pharmacotherapy for neuropathic pain, including unpublished trials (retrieved from clinicaltrials.gov and pharmaceutical websites). Meta-analysis used Numbers Needed to Treat (NNT) for 50 % pain relief as primary measure and assessed publication bias. Recommendations used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Findings In total 229 studies were included. Analysis of publication bias suggested a 10% overstatement of treatment effects. Studies published in peer-review journals reported greater effects than online studies (R2=9·3%, p<0·01). Trial outcomes were generally modest even for effective drugs : in particular NNTs were 3·6 (95 % CI 3·0–4·4) for tricyclic antidepressants (TCAs), 6·4 (95 % CI 5·2–8·4) for serotonin- noradrenaline reuptake inbibitor (SNRI) antidepressants duloxetine and venlafaxine, 7·7 (95 % CI 6·5–9·4) for pregabalin and 6·3 (95 % CI 5·0–8·3) for gabapentin. NNTs were higher for gabapentin ER/enacarbil and capsaicin high concentration patches, lower for opioids and botulinum toxin A (BTX-A) and undetermined for lidocaine patches. Final quality of evidence was lower for lidocaine patches and BTX-A. Tolerability/safety and values/preferences were high for lidocaine patches and lower for opioids and TCAs. This permitted a strong GRADE recommendation for use and proposal as first line for TCAs, SNRIs, pregabalin, gabapentin and gabapentin ER/enacarbil in neuropathic pain, a weak recommendation for use and proposal as second line for lidocaine patches, capsaicin patches and tramadol, and a weak recommendations for use and proposal as third line for strong opioids (particularly oxycodone and morphine) and BTX-A. Data for cannabinoids, tapentadol, drug combinations, and several other antiepileptics, antidepressants and topical drugs were inconclusive. Interpretation Limited efficacy, large placebo responses, inadequate diagnostic criteria and poor phenotypic profiling probably account for modest trial outcomes and should be taken into account in future studies. Funding This study was funded by NeuPSIG.

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Section: Discussionmentioning

confidence: 96%

“…2,6,7 This may be due to lack of diagnostic accuracy and relatively ineffective drugs, but also insufficient knowledge about effective drugs and their appropriate use in clinical practice. 8 Evidence-based recommendations for the pharmacotherapy of neuropathic pain are therefore essential.…”

Section: Introductionmentioning

confidence: 99%

Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis

Finnerup

Attal

Haroutounian

et al. 2015

The Lancet Neurology

3,091

2,119

View full text Add to dashboard Cite

show abstract

“…In the USA, a study by Dworkin and colleagues [15] suggested that the drug treatment of post-herpetic neuralgia by primary care physicians was roughly consistent with the US recommendations issued some years before. However, this study was retrospective and restricted to post-herpetic neuralgia, a condition that is easier for non-specialists to diagnose than many other neurological pain conditions.…”

Section: Introductionmentioning

confidence: 70%

Adherence of French GPs to Chronic Neuropathic Pain Clinical Guidelines: Results of a Cross-Sectional, Randomized, “e” Case-Vignette Survey

Martinez

Attal

Vanzo³

et al. 2014

PLoS ONE

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Background and aimsThe French Pain Society published guidelines for neuropathic pain management in 2010. Our aim was to evaluate the compliance of GPs with these guidelines three years later.MethodsWe used “e” case vignette methodology for this non interventional study. A national panel of randomly selected GPs was included. We used eight “e” case-vignettes relating to chronic pain, differing in terms of the type of pain (neuropathic/non neuropathic), etiology (cancer, postoperative pain, low back pain with or without radicular pain, diabetes) and symptoms. GPs received two randomly selected consecutive “e” case vignettes (with/without neuropathic pain). We analyzed their ability to recognize neuropathic pain and to prescribe appropriate first-line treatment.ResultsFrom the 1265 GPs in the database, we recruited 443 (35.0%), 334 of whom logged onto the web site (26.4%) and 319 (25.2%) of whom completed the survey. Among these GPs, 170 (53.3%) were aware of the guidelines, 136 (42.6%) were able to follow them, and 110 (34.5%) used the DN4 diagnostic tool. Sensitivity for neuropathic pain recognition was 87.8% (CI: 84.2%; 91.4%). However, postoperative neuropathic pain was less well diagnosed (77.9%; CI: 69.6%; 86.2%) than diabetic pain (95.2%; CI: 90.0%; 100.0%), cancer pain (90.6%; CI: 83.5%; 97.8%) and typical radicular pain (90.7%; CI: 84.9%; 96.5%). When neuropathic pain was correctly recognized, the likelihood of appropriate first-line treatment prescription was 90.6% (CI: 87.4%; 93.8%). The treatments proposed were pregabaline (71.8%), gabapentine (43.9%), amiptriptylline (23.2%) and duloxetine (18.2%). However, ibuprofen (11%), acetaminophen-codeine (29.5%) and clonazepam (10%) were still prescribed.ConclusionsThe compliance of GPs with clinical practice guidelines appeared to be satisfactory, but differed between etiologies.

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“…Pain and its interference with daily activities are subjective symptoms and difficult to manage effectively, even more so in older patients, who are predominantly afflicted with PHN, and who are more likely to have multiple chronic health issues and declining function and frailty 29,30. A significant number of patients who develop chronic pain associated with PHN do not receive evidence-based, recommended treatment modalities, leaving many patients undertreated and dissatisfied with the treatment 24,31,32. To ensure optimal results, the initial choice of PHN pain therapy should be guided not only by drug efficacy but also by the patient’s comorbidities, severity of PHN pain, the drugs’ adverse-event and drug-interaction profiles, titration regimen, and patient preference, especially since no single therapy has demonstrated superior effectiveness.…”

Section: Practical Considerations For Management Of Phnmentioning

confidence: 99%

Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider

Massengill¹,

Kittredge²

2014

JPR

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An estimated one million individuals in the US are diagnosed with herpes zoster (HZ; shingles) each year. Approximately 20% of these patients will develop postherpetic neuralgia (PHN), a complex HZ complication characterized by neuropathic pain isolated to the dermatome that was affected by the HZ virus. PHN is debilitating, altering physical function and quality of life, and commonly affects vulnerable populations, including the elderly and the immunocompromised. Despite the availability of an immunization for HZ prevention and several approved HZ treatments, the incidence of PHN is increasing. Furthermore, management of the neuropathic pain associated with PHN is often suboptimal, and the use of available therapeutics may be complicated by adverse effects and complex, burdensome treatment regimens, as well as by patients’ comorbidities and polypharmacy, which may lead to drug–drug interactions. Informed and comprehensive assessments of currently available pharmacological treatment options to achieve effective pain control in the primary care setting are needed. In this article, we discuss the situation in clinical practice, review currently recommended prevention and treatment options for PHN, and outline practical considerations for the management of this neuropathic pain syndrome, with a focus on optimal, individual-based treatment plans for use in the primary care setting.

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Is treatment of postherpetic neuralgia in the community consistent with evidence-based recommendations?

Cited by 31 publications

References 40 publications

Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis

Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis

Adherence of French GPs to Chronic Neuropathic Pain Clinical Guidelines: Results of a Cross-Sectional, Randomized, “e” Case-Vignette Survey

Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider

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