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Page 1 of 3 Nanna B. Finnerup, MD; Marit Otto, MD; Troels S. Jensen, MD, PhD; Søren H. Sindrup, MD, PhD
Abstract
 Objective: The purpose of this article is to discuss an evidence-based algorithm that can be implemented by the primary care physician in his/her daily clinical practice for the treatment of patients with neuropathic pain conditions.
Method: A treatment algorithm for neuropathic pain was formulated on the basis of a review of 105 high-quality, randomized, placebo-controlled clinical trials. The number needed to treat (NNT) and number needed to harm (NNH) were used to compare the safety and effectiveness of current treatments for neuropathic pain syndromes. Most of the clinical trials reviewed in the analysis assessed tricyclic antidepressants (TCAs) and antiepileptic drugs (AEDs).
Results: TCAs had the lowest NNT followed by opioids and AEDs, such as gabapentin and pregabalin. The nature of the retrospective calculation of the NNT and NNH involves obvious limitations because of the pooling of studies with different experimental designs and outcomes.
Conclusion: Patients presenting with neuropathic pain are becoming a more frequent occurrence for the primary care physician as the population ages. Evidence-based treatment options allow for the most efficient and effective pharmacotherapy regimen to be implemented.
Introduction
Given the significant and growing prevalence of neuropathic pain, estimated to affect up to 3% of the population[1] (a pooled estimate[1-7]) and that approximately 1 in 5 European adults reports chronic pain,[8] the value of proper treatment options derived from the systematic review of randomized, placebo-controlled clinical trials cannot be underestimated. Neuropathic pain is distinct from other (nociceptive) types of commonly reported pain conditions, including headache, back pain, and other types of musculoskeletal pain. Neuropathic pain may occur in diabetic sensorimotor polyneuropathy, the most common type of generalized polyneuropathy,[9] which affects approximately 54% of patients with type 1 diabetes and 45% of patients with type 2 diabetes, and neuropathic pain thus develops in up to 25% of patients with diabetes.[10,11] Approximately 800,000 cases of shingles are reported each year in the United States, with 25% to 50% of those cases developing postherpetic neuralgia (PHN), a neuropathic pain condition resulting from infection by the herpes zoster virus.[3] Neuropathic pain can develop from HIV/AIDS, various toxins (eg, neurotoxins), alcohol abuse, acute trauma (including surgery), chronic trauma (eg, repetitive motion disorders, such as carpal tunnel syndrome, the most common of the mononeuropathies, affecting 2.8% to 4.6% of the adult population[12-14]), central nervous system diseases (such as stroke, multiple sclerosis, and spinal cord injury), or autoimmune conditions (such as celiac disease).[15]
The necessity of such an evidence-based treatment algorithm for use by primary care physicians (PCPs) is further highlighted as patients presenting with pain (complaints of all types of pain) represent the most common reason to seek medical attention,[16,17] and account for approximately 25% to 50% of primary care visits, with 20% of these visits due to persistent chronic pain conditions.[18,19] In the United States, 9 out of 10 adults 18 years and older report experiencing pain at least once a month and 42% reported pain on a daily basis.[16] Compared with patients without chronic pain, a study using data from a Danish multidisciplinary pain center found that those patients with chronic pain are 5 times more likely to use healthcare services.[20] As such, it is even more critical for the PCP to identify those cases of neuropathic pain that can be best treated either by the PCP alone, through referral to a pain specialist who will, with the PCP, manage the patient with the help of 1 or 2 other clinicians in those cases of moderate complexity (eg, persistent, treatment-resistant neuropathic pain, comorbid psychiatric condition, necessity of invasive procedures), or with a multidisciplinary team approach in cases of high complexity.
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Research 
Objective: The purpose of this article is to discuss an evidence-based algorithm that can be implemented by the primary care physician in his/her daily clinical practice for the treatment of patients with neuropathic pain conditions.
