Key notes on symptom control issues in Palliative Care

Neuropathic pain

Neuropathic pain
Step one	Treat reversible causes if possible	Follow the WHO ladder
Step two	Start either an antidepressant or anticonvulsant	Add in the agent of the class not already in use
Step three	Trial of steroids	Ask for help – may need a nerve block

Is partially opioid responsive and so the patient should be titrated on short acting oral morphine sulphate as for visceral pain. At the same time they should also be started on a neuropathic analgesic. The choice of what to use will depend on the side effect profile and the risk / benefit assessment for each patient. Usually this type of pain is difficult to manage and the early involvement of the specialist palliative care team should be considered. The agents commonly used are:

• 
  Amitriptyline starting at 25mg (10mg in the elderly) in a single night time dose and increasing by 25mg every 3 days to a dose of 75-100mg depending on response.
  
• 
  Sodium valproate starting at 200mg 12hourly and increasing by 200mg every three days to a maximum of 2.4g depending on response.
  

• 
  Gabapentin starting at a dose of 300mg daily and increasing to 300mg twice daily on day 2, then 300mg 3 times a day on day 3 then increasing by 300mg every three days to a maximum dose of 1.8g, depending on response
  

• 
  Local nerve blockade may help. Pain anaesthetists may be able to give advice.