Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Related guidance: CG173 Neuropathic pain - pharmacological management: NICE guideline Updated July 2019
NICE recommendation for the pharmacological management of neuropathic pain depends on diagnosed origin of the pain.
There is no need to change existing treatments for people whose neuropathic pain is well controlled
 All pharmacological treatments should be started at a low dose & titrated to maximum effective or tolerated dose
 When switching to a new drug, consider overlapping treatments to avoid deterioration in pain control
 When withdrawing, taper the dose to avoid discontinuation symptoms
 If pain reduction is still unsatisfactory at maximum doses of first & second line treatments refer patient to a specialist pain and/or condition specific service
Do not start treatment with opioids (such as morphine or oxycodone) other than tramadol without an assessment by a specialist pain service or a condition-specific service
Low back pain and sciatica in over 16s:assessment and management September 2020 - NICE has reviewed the evidence and made new recommendations on the pharmacological management for people with sciatica, including not to offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines; it also recommends against opioids for chronic sciatica.
Neuropathic painAmitriptyline10mg tablets: £1.01
25mg tablets: £0.87
50mg tablets: £2.28
Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)
If the initial treatment is not effective or is not tolerated, offer one of the remaining 3 drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

Duloxetine60mg G/R capsules: £2.39
Gabapentin100mg capsules: £2.00 (100)
300mg capsules: £3.48 (100)
400mg capsules: £4.25 (100)
Pregabalin25mg capsules: £2.79 (56)
50mg capsules: £3.65 (84)
75mg capsules: £3.03 (56)
100mg capsules: £4.72 (84)
150mg capsules: £3.66 (56)
200mg capsules: £5.22 (84)
225mg capsules: £4.23 (56)
300mg capsules: £5.55 (56)
Because of price structure for pregabalin, ensure dose optimisation is carried out.
Pregabalin dose spread over two daily doses proved non-inferior to three times a day dosing:
Tramadol capsules
(immediate release)
50mg capsules: £2.83 (100)Consider tramadol only if acute rescue therapy is needed.
NB The combination of tramadol with amitriptyline or duloxetine is associated with a low risk of serotonin syndrome.
Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.
Lidocaine Patches

as Ralvo®
700mg medicated plaster:
£61.54 (pack 30)
Indicated for the symptomatic relief of neuropathic pain associated with previous herpes zoster infection (post-herpetic neuralgia, PHN) in adults.

Max use 12 hours per day re-evaluate need every 2 weeks.

Long term use not recommended.

Trusts initiating prescribing for acute fracture pain should discharge patient with full course - GPs should NOT continue use for off-license indications.
Capsaicin cream as Axsain®0.075% cream, 45g=£14.58.