Neuropathic pain: Information for clinicians

This information is sourced from Scottish Palliative Guidelines, and the MHRA

Neuropathic pain is a common complication of cancer and may be due to: 

  • vertebral metastases from prostate, lung, bowel and breast cancer causing root or cord compression
  • breast cancer brachial plexopathy 

Other causes of neuropathic pain include:

  • neurological illnesses such as Multiple Sclerosis
  • treatment e.g. chemotherapy-induced peripheral neuropathy
  • other co-morbid conditions e.g. post-herpetic neuralgia or diabetic neuropathy
Red flags

Always consider spinal cord compression in patients with neuropathic pain.

Key symptoms of cord compression include:

  • new intractable, progressive pain, especially thoracic or legs. 
  • New spinal nerve root pain may radiate down the leg (like sciatica), or the arm, or more like a band around the chest or abdomen
  • Coughing, straining or weight bearing may aggravate pain
  • New difficulty walking or climbing stairs; reduced power and heavy legs

Late signs include:

  • Sensory impairment at an abdominal or thoracic level plus altered limb sensation
  • Bowel or bladder disturbance; loss of sphincter control 
Clinical features
  • Patients often describe neuropathic pain as burning, shooting, tingling or stabbing in nature
  • Altered sensation is also a symptom. Sensitivity to light touch may be reduced or increased (allodynia)
  • Pain may follow a dermatomal distribution

When examining always compare both sides of the body.

An initial approach to treatment
  • Tricyclic antidepressants e.g. Amitriptyline 10mgs at night and titrate to 25mg 
  • Anticonvulsant e.g. Pregabalin or Gabapentin. Pregabalin is a BD dosage and easier to titrate than Gabapentin. Remember that Pregabalin and Gabapentin are sedative in combination with opioids 
  • Duloxetine is another alternative and may help mood as well as pain
  • A combination of neuropathic agent, Paracetamol and opioid analgesics may be needed 
  • Bloods to exclude a metabolic cause e.g. B12 deficiency
Specialist care

If the above approaches are not working and sleep in disturbed, then specialist advice is recommended. Options include:

  • Dexamethasone 6mg for 6 days (or 40mg Prednisolone) with PPI cover for urgent control of neuropathic pain. This takes the pressure off the nerve
  • Other anticonvulsants may be tried e.g. Oxcarbazepine 150mg BD
  • Urgent MRI to inform whether further intervention is needed e.g. radiotherapy, surgery or nerve block 

Recommended Resources

Scottish Palliative Care Guidelines - Neuropathic pain

Published 14th April 2022

MHRA Pregabalin (Lyrica): reports of severe respiratory depression

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