POEMs

Patient-Oriented Evidence That Matters

Anticonvulsants, SNRIs, and Rubefacients Are Best Initial Choices for Chronic Pain Caused by Diabetic Neuropathy or Postherpetic Neuralgia

 

Am Fam Physician. 2021 Nov ;104(5):online.

Clinical Question

Which treatments for chronic neuropathic pain can provide clinically meaningful improvement?

Bottom Line

Given the balance of benefits and harms, there is moderately good evidence for anticonvulsants (pregabalin [Lyrica] and gabapentin [Neurontin] were similarly effective and well tolerated) and serotonin-norepinephrine reuptake inhibitors (SNRIs; with duloxetine [Cymbalta] and venlafaxine being similarly effective and well tolerated) for treating diabetic neuropathy and postherpetic neuralgia. Rubefacients (usually salicylates) appear to be effective but are less well studied with low-quality evidence. Acupuncture, opioids, and tricyclic antidepressants cannot be recommended based on current evidence. (Level of Evidence = 1a–)

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SUMMARY TABLE

InterventionStudies (participants)Number needed to treat (95% CI)Number needed to harmQuality

Anticonvulsants

40 (9,575)

7

17 to 22

Moderate

Serotonin-norepinephrine reuptake inhibitors

8 (2,746)

7

13

Moderate

Rubefacients

10 (2,344)

7

25

Low

Opioids

6 (1,149)

8

12

Low

SUMMARY TABLE

InterventionStudies (participants)Number needed to treat (95% CI)Number needed to harmQuality

Anticonvulsants

40 (9,575)

7

17 to 22

Moderate

Serotonin-norepinephrine reuptake inhibitors

8 (2,746)

7

13

Moderate

Rubefacients

10 (2,344)

7

25

Low

Opioids

6 (1,149)

8

12

Low

Synopsis

This report describes findings from a series of meta-analyses of placebo-controlled randomized trials of at least three months' duration on the effectiveness of drug and nondrug treatments for chronic neuropathic pain, with a focus on diabetic neuropathy, postherpetic neuralgia, and trigeminal neuralgia. Only studies that provided results as the presence or absence of a clinically meaningful response, defined as at least a 30% improvement on a scale of pain and/or function, were included. Studies in pregnant patients, of acute pain, and those with an active comparator were excluded. The authors found no qualifying studies for trigeminal neuralgia, or for topical lidocaine or exercise as interventions. The authors identified 40 randomized controlled trials with moderate certainty of evidence for anticonvulsants; the bulk of the evidence was for pregabalin and gabapentin, and both were effective (number needed to treat [NNT] = 7 for one patient to respond; number need to harm [NNH] = 17 to 22 for withdrawal due to adverse events). Rubefacients (topical drugs that cause irritation and redness of skin) were studied in 10 randomized controlled trials with low certainty of evidence; low-dose patches or creams and high-potency patches

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.

 

 

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