guidelines for the treatment of cancer-related neuropathic pain...neuropathic pain questionnaire are...

Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Group Guidelines

Guidelines for the Management of Cancer-related Neuropathic Pain Date of Production: July 2018

Date of Review: July 2021

1

Guidelines for the Treatment of Cancer-related Neuropathic Pain

S Coyle,1 L McGlynn,

2 G Ting,

3, S Simpson,

4 E Sulaivany,

5 G Leng,

6 K Marley.

3 (Guideline

Development Lead)

1Willowbrook Hospice, Prescott;

2 Aintree University Hospital NHS Foundation Trust, Liverpool;

3 Woodlands Hospice,Liverpool;

4

Southport and Ormskirk Hospital NHS Trust, Southport;5 St Rocco’s Hospice, Warrington;

6 Hospice of the Good Shepherd,

Chester.

Summary Of Main Recommendations

Neuropathic pain has been defined as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system” and is

common amongst patients with cancer.1,2

The evidence base for the treatment of cancer-related neuropathic pain is limited.

Pharmacological Management

The evidence supports the use of the following adjuvants in the treatment of cancer-related neuropathic pain: Gabapentin, Pregabalin and Amitriptyline. If there is no response to the initial adjuvant drug consider switching drug.

If there is partial response, consider adding a drug from a different class.

If no response or only a partial response then

consider alternative drugs or approaches and refer for anaesthetic intervention.

Non Pharmacological Options

Although the evidence is lacking for cancer-related neuropathic pain, non-pharmacological approaches should be considered alongside pharmacological therapies. This may include: transcutaneous electrical nerve stimulation (TENS); acupuncture; hydrotherapy and psychological interventions.

13-15

Interventional Pain Techniques

Interventional techniques may be indicated and should be discussed at an early stage with an Anaesthetic Pain Specialist.

11,12

Standards for Assessment and Management

Response to intervention for neuropathic pain should be monitored with pain scores/VAS before and after intervention.[Grade D]

Patients with severe pain or pain that is affecting ADLs should have at least weekly follow-up if an outpatient. The patient should be reassessed every 24 hours if an in-patient. [Grade D]

If neuropathic pain is escalating despite appropriate medical treatment, an Anaesthetic Pain Specialist should be contacted for advice within one week where available. [Grade D]

Clinical Assessment

A detailed history and clinical examination is essential. Investigations such as computerised tomography (CT) or magnetic resonance imaging (MRI) may be appropriate.

Screening tools are available to aid in the diagnosis of neuropathic pain such as the McGill Pain Questionnaire, S-LANSS and Neuropathic Pain Questionnaire.

Although screening tools are readily available they have not been specifically validated for the diagnosis of cancer-related neuropathic pain.

General Management Principles

The WHO analgesic ladder should be used.

Strong opioids should be titrated against response. There is no evidence to suggest the superiority of one strong opioid over another.

Adjuvants and non-opioids should be used as appropriate.

There is no evidence to recommend the routine first line use of NSAIDs in neuropathic cancer-related pain.

The endpoint of titration is pain relief or intolerable side effects. If dose-limiting side effects occur despite the use of adjuvants or other interventions, a switch of strong opioid should be considered.




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Section 1: Introduction

Neuropathic pain is common in patients with cancer. The Neuropathic Pain Special Interest Group (NEUPSIG) has redefined neuropathic pain as: “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.” 1,2.

Currently, there is no gold standard test available to diagnose neuropathic pain. However, screening tools such as the McGill Pain Questionnaire, S-LANSS and the Neuropathic Pain Questionnaire are available within clinical practice to aid in the diagnosis of neuropathic pain. Although screening tools are readily available they have not been specifically validated for the diagnosis of cancer-related neuropathic pain.3

Neuropathic pain can be challenging to manage in clinical practice particularly as a result of the heterogeneity of the multiple aetiologies. Within the literature there is limited evidence specific to the management of cancer-related neuropathic pain. One of the primary aims of this guideline is to review the literature and current evidence base. The following guidance is an update of Merseyside and Cheshire Specialist Palliative Care Audit Group Guidelines for the Management of Cancer-related Neuropathic Pain developed in 2004 and updated in 2009.4

Section 2: Scope and Purpose This guideline is aimed primarily at practitioners in specialist palliative care including doctors, nurses, physiotherapists, occupational therapists and pharmacists. The guideline may also be of benefit to generalist providers of palliative care such as general practitioners, district nurses and those in secondary care.

The aims of the guideline are to:-

• Identify evidence based treatments for cancer-related neuropathic pain

• Provide guidance for the treatment of cancer-related neuropathic pain




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Table 1: Summary of scope and purpose for this guideline.

Table 1: Scope of guideline

Population • Adults with cancer-related neuropathic pain

Populations not covered • Under 18 years of age, adult non cancer-related neuropathic pain

Healthcare setting

• People in their usual place of residence • Primary and community care • Secondary care • Hospice care

Topics

• Definition and diagnosis of cancer-related neuropathic pain

• Review of existing guidelines for the treatment of cancer-related neuropathic pain

• Role of opioids in the management of cancer-related neuropathic pain

• The role of adjuvants in cancer-related neuropathic pain

• The role of non-pharmacological approaches to managing cancer-related neuropathic pain

Topics not covered • Management of treatment related neuropathic pain • Management of non cancer-related neuropathic pain

Section 3: Methods The guideline is based on the AGREE II criteria which can be found in detail in the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual.5 Clinical Questions & Interventions

Clinical questions were derived from the previous guidance published in 2004 and reviewed in 2009.4 These were then refined by the Guideline Development Group which has authored this guideline. Specific clinical questions were formulated and used to guide the literature review. The PICO format (Patient, Intervention, Control, and Outcome) was adopted. The clinical questions used to review the evidence were as follows: What is the definition of cancer-related neuropathic pain? How is cancer related to neuropathic pain?




4

What are the existing guidelines for the treatment of cancer-related neuropathic

pain? Do opioids have a role in the management of cancer-related neuropathic pain? Are particular opioids better than others in the management of cancer-related

neuropathic pain? What is the evidence for the use of the following agents in cancer-related

neuropathic pain? - Anti-depressants - Anticonvulsants - Corticosteroids - Clonazepam - Capsaicin - Lidocaine - Tapentadol

What is the evidence for the following non-pharmacological approaches to managing cancer-related neuropathic pain? - TENS - acupuncture - hydrotherapy - psychological interventions

Outcomes

To improve the management of cancer-related neuropathic pain Literature Search

Systematic electronic database searches were undertaken to find potentially relevant articles. Ovid MEDLINE, EMBASE, CINAHL and Cochrane databases were searched in December 2013. A full explanation of the search strategy, results and appraisal of evidence can be found in Appendices 1-12. Grading of the level of evidence and recommendations follows the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual and uses SIGN criteria.5

Section 4: Guideline Recommendations

4.1. General Principles

Neuropathic pain may be relieved in the majority of patients by multimodal management. 6,7

A careful history and examination are essential.6 Investigations such as computerised tomography (CT) or magnetic resonance imaging (MRI) may be appropriate.7




5

It is important to have a logical and rational approach to prescribing. Pain diaries

may be useful to assess effect of intervention. Chemotherapy or radiotherapy may be indicated if the tumour is chemosensitive

or radiosensitive.8-12

Although the evidence is lacking for cancer-related neuropathic pain, non-pharmacological approaches should be considered alongside pharmacological therapies. This may include: transcutaneous electrical nerve stimulation (TENS); acupuncture; hydrotherapy and psychological interventions.13-15

Interventional techniques may be indicated and should be discussed at an early stage with an Anaesthetic Pain Specialist.16,17

4.2. Assessment and Monitoring

Undertake regular clinical reviews to assess and monitor the effectiveness of the treatment. Each review should include an assessment of:-

Pain control

Impact on lifestyle, daily activities (including sleep disturbance) and participation

Physical and psychological wellbeing

Adverse effects

Continued need for treatment 18

4.3. Pharmacological Management The WHO analgesic ladder should be followed.19

Strong opioids should be titrated against response. There is no evidence to

suggest the superiority of one strong opioid over another.20 Adjuvants and non-opioids should be used as appropriate. There is no evidence that the routine first line use of NSAIDs has a major role in

cancer-related neuropathic pain but they may be of some benefit.49

When using strong opioids, if dose limiting or intolerable side effects occur despite the use of adjuvants or other interventions, a switch of opioid could be considered.21

Figure 1 features a flow diagram which may be a useful guide for adjuvant prescribing in cancer-related neuropathic pain. [Level 1-]

If nerve compression is suspected, a trial of a short course of corticosteroids could be considered, although the evidence is weak. 22,23 For example use Dexamethasone 8mg daily for 5 days.24-26 Discontinue if no response. Reduce to lowest dose to maintain effect.27 If good response then the patient may benefit from radiotherapy. Monitor blood sugar levels. Consider gastric protection.28

4.4. Anaesthetic Intervention

Consider referring to anaesthetic pain specialists at any stage, including at initial presentation and at regular clinical reviews if:-

The patient has severe pain and/or escalating pain or

Pain significantly limits lifestyle, daily activities (including sleep disturbance) and participation.18 [Level 4]

For anaesthetic approaches see MCCN Guidelines on Interventional Pain




6

Techniques.29

Anaesthetic intervention should not be considered as a last resort. [Level 4] 4.4. Complex Neuropathic Pain In patients with symptoms that are difficult to control or who have severe

allodynia / hyperalgesia, consider admission to a specialist unit. [Level 4] For treatment of resistant cancer-related neuropathic pain, Methadone and/or

Ketamine could be considered in a specialist palliative setting. (See MCCN Guidelines for Methadone and Ketamine use).30.31.

In patients who continue to have uncontrolled pain despite use of opioids, anticonvulsants and tricyclic antidepressants, medications which have been shown to be helpful in neuropathic pain not related to cancer could be tried as recommended in the current NICE guidelines for the management of neuropathic pain.18 See Table 1 for examples.

4.5. Parenteral Medication Patients who are unable to take oral analgesics and have ongoing pain should

be discussed with a senior Palliative Medicine physician. Strong opioids may be given via a continuous subcutaneous infusion. There are

no injectable options for the more commonly used adjuvants such as anticonvulsants and antidepressants.

Clonazepam may be given by continuous subcutaneous infusion but the evidence is weak.32 [Level 3]

4.6, Stopping Treatment In the event of a patient no longer requiring adjuvants for neuropathic pain, the

medication can be discontinued as recommended by the medication Summary of Product Characteristics (SPC):-

Duloxetine should be gradually tapered over a period of no less than two weeks, according to the patient's needs.

Gabapentin or Pregabalin should be discontinued gradually over a minimum of one week, independent of the indication.

There is no clear guidance for Amitriptyline but it is recommended that it is discontinued gradually.

For other medications please refer to the current British National Formulary.

The gradual reduction of medication may not be possible in patients who are in the last hours or days of life.




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Figure 1. Approaches to adjuvant analgesics in cancer-related neuropathic pain




8

Table 1. Medication with an evidence base in the management of cancer-related

neuropathic pain

Drug Name Initial Dose Titration Side Effects Notes

Amitriptyline 33,34

[Level 1-]

10mg-25mg nocte

10mg at night in the

elderly.

Increase every 3

days as

tolerated

Occur in 33%

of patients.

Include

drowsiness

and dry mouth

Speed of onset 1-7 days.

May get improved sleep pattern

and mood.

Use with caution in : cardiac

disease; arrhythmias; epilepsy;

concurrent use of SSRIs; angle

closure glaucoma; history of

urinary retention

Gabapentin 33, 35-39

[Level 1-]

300mg nocte.

100mg nocte in the

elderly

Increase after 3

days to 300mg

bd. Increase to

300mg tds after a

further 3 days.

Maximum dose is

3600mg. Note:

May need to use

slower titration

regimen e.g. start

at 100mg od and

increase by

100mg every 2

days

Sedation,

dizziness. Reduce dose in renal failure /

impairment.

Use in caution in patients with

CCF.

Diabetic patients may need to

adjust hypoglycaemic treatment

as weight gain may occur.

Pregabalin 33,40-42

[Level 1-]

Day 1: 25mg od

Day 2: 25mg bd

Increase every 2

days by 25mg bd

150mg-600mg

daily in 2

divided doses.

Avoid tds

dosing.

Sedation,

dizziness Potential pharmacodynamic

interactions with all opioids and

sedatives.

Caution may be required in

patients with chronic heart

failure.

Diabetic patients may need to

adjust hypoglycaemic treatment

as weight gain may occur.

Morphine 37

[Level 1-]

Oramorph 2.5mg -

5mg PRN

Convert to a

sustained

release

morphine

preparation as

clinically

indicated

Beware of

opioid toxicity

Oxycodone 40

[Level 1-]

Oxynorm 1mg-2mg

PRN if opioid naive

Convert to a

sustained

release

oxycodone

preparation as

clinically

indicated

Beware of

opioid toxicity




9

Table 2. Medications with an evidence base in non cancer-related neuropathic pain

Drug Name Initial Dose Titration Side Effects Notes

Duloxetine 47

[Level 1+]

60mg od Maximum 120mg per day in divided doses

Nausea, dry mouth, constipation, fatigue

Licensed for painful diabetic neuropathy

Capsaicin 0.075% cream

43

[Level 1-]

Apply topically 3 or 4 times daily

Skin burning and redness

May take up to 10 days to have an effect. Always wear gloves when applying

Carbamazepine 44

[Level 1-]

200mg daily 100mg daily in the elderly

Increase by 100mg-200mg every 3 days. Give in divided doses

Nausea, drowsiness, confusion and ataxia

Beware of drug interactions

Lidocaine patch 45

[Level 1-]

One strength. Apply for 12 hours daily over painful area and then remove.

Can use up to 3 patches at

any one time.

Skin reaction. Current evidence is for post herpetic neuropathic pain. May be useful for post thoracotomy pain.

Sodium Valproate

46

[Level 2-]

200mg nocte Increase by 200mg every 3 days. Maximum dose is 1000mg daily

Nausea, ataxia

Clonazepam 32

[Level 3]

500 micrograms nocte

Increase by 500mcg every 3 days. Maximum dose is 8mg

Sedation May be given subcutaneously via a syringe driver. May adsorb to PVC so use non PVC equipment for infusions.




10

Sectin 5: Standards

1. Response to intervention for neuropathic pain should be monitored with pain scores/VAS, before and after intervention.4,7,48 [Grade D]

2. Patients with severe pain or pain that is affecting their ADLs should have at least weekly follow-up if an outpatient, and 24 hourly re-assessment if an in-patient.[Grade D]

3. If neuropathic pain is escalating despite appropriate medical treatment, an Anaesthetic Pain Specialist should be contacted for advice within one week where available. [Grade D]

Applications and Implications

The most pressing implication is for the education and training of palliative care professionals. Following publication, this guideline will be available to healthcare professionals online via the Merseyside and Cheshire Cancer Network website. Other means of increasing awareness regarding the management of cancer-related neuropathic pain include:- Discussion of this guideline during palliative medicine trainee induction

programmes and nursing staff inductions Audit meetings GP training / educational events Meetings with community specialist palliative care teams

Implications for practice include:- Healthcare professionals unaware of the guideline may not be prescribing in

accordance with the evidence base Access to anaesthetic pain specialists may vary throughout the region Capacity for weekly review of patients in clinics or the community Cost of medications may influence prescribing choices

Recommendations for research and service improvement include:- To re-audit this topic and the evidence based literature in three years after

publication Local case note reviews / audit of prescribing Ongoing education and raising awareness of guideline availability




11

Acknowledgments and Declarations of Interest

Authors

Dr Seamus Coyle, Consultant in Palliative Medicine.

Laura McGlynn, Specialty Registrar in Palliative Medicine.

Dr Grace Ting, Specialty Registrar in Palliative Medicine.

Steve Simpson, Pharmacist

Dr Esraa Sulaivany, Associate Specialist in Palliative Medicine.

Dr Graham Leng, Consultant in Palliative Medicine.

Dr Kate Marley, Consultant in Palliative Medicine (Guideline Development Lead)

All authors have declared no conflict of interest in developing this guideline. Guideline production was funded through supporting professional activity time facilitated by the employing organisations of the authors. We gratefully acknowledge the work of:

Dr Helen Emms, Dr Clare Douglas, Professor Matt Makin and Dr Andrew Jones who developed the original guideline.

The Library Service at Bridgewater Community Healthcare NHS Trust for help with the literature searches.

Mr and Mrs F Rogers and Angela Fell our patient representatives.

Members of the Cheshire and Merseyside Palliative and End of Life Care Audit Group who submitted data for the regional audit which formed part of this project and also for contributing to guideline development through expert opinion.

Professor Mike Bennett, Professor of Palliative Medicine, University of Leeds and St Gemma’s Hospice who externally reviewed this guideline.

The authors contributed as follows: Literature Review: SC, LMcG, GT, SS, ES, GL KM. Audit Tools: SC, LMcG, GT, ES, GL KM. Updating Guidance and Grading SC, LMcG, GT, SS, ES, GL KM. Recommendations: SC, LMcG, GT, SS, ES, GL KM. Standards: SC, LMcG, GT, SS, ES, GL KM. Final writing of manuscript of guidelines: SC LMcG, KM, ES, GL.

Review Date

The guidelines will be reviewed three years after publication as outlined in the Cheshire and Merseyside Palliative and End of Life Care Network Audit Group Guideline Development Manual




12

Appendix 1: Systematic Review Summary Form

Guideline Title: Neuropathic pain in cancer Reviewers: S Coyle G Ting

Records identified Medline

(n = 206)

Records screened (n = 206)

Records excluded (n = 23)

73 – non-cancer pain 35 – non-neuropathic pain 40 – Treatment related 40 – Review articles 6 – Non-anticonvulsants

Full-text articles assessed for eligibility

(n = 13)

Full-text articles excluded, with reasons

(n = 3) 1 case series 1 descriptive study 1 retrospective study

Studies included in final literature review

(n = 10)

MEDLINE was searched using the following terms: ((cancer pain) AND anticonvulsant*) NOT non-cancer

Filters 10years, Humans, English

Role on Anticonvulsants in Cancer-related Neuropathic pain

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Role on Hydrotherapy in Cancer-related Neuropathic pain



Records identified Medline

(n = 21)



7 – non-cancer pain 9 – non-hydrotherapy 5 –non-Neuropathic pain


(n = 0)


(n = 0)

MEDLINE was searched using the following terms: ((cancer pain) AND hydrotherapy) NOT non-cancer


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Records identified Medline (n = 59)



8 – non-cancer pain 7 – non-neuropathic pain 6 – Treatment related 30 – Non guideline 3 – Non-adult 2 – unrelated to criteria


(n = 6)


(n = 0)


(n = 6)

MEDLINE was searched using the following terms: ((cancer pain) AND anticonvulsant*) NOT non-cancer


Existing Guidelines for Cancer- related Neuropathic Pain

Records identified through other

sources (3) (n = 3)

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Records after duplicates removed n = 16

Records screened n = 24

Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text; Biomedical Reference. Filters 10years, Humans, English

Collection: Comprehensive;MEDLINE

Search Terms: “Neuropathic pain” AND “Capsaicin OR cancer”

Records identified 24

articles n = 24

What is the evidence for the use of Capsaicin in cancer- related neuropathic pain?


Guideline Title: Neuropathic pain in cancer

Reviewers: L McGlynn, K Marley

Records excluded (n=15)

15 – Irrelevant to cancer related neuropathic pain


(n = 1)


(n = 0)


(n = 0)

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17

What is the definition of neuropathic pain and how do we diagnose it?



(n = 32)


n = 29 irrelevant

Studies included in final

literature review (n=3)

1 further article included but not found in literature search

(n=4)





Records excluded (n= 8 )

5 – Not available in English language

3 – Unable to access


articles n = 55

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Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text;Biomedical Reference Collection: Comprehensive;MEDLINE Search Terms: “diagnosis” “assessment” “neuropathic” “pain” “cancer” “patients” Filters 10years, Humans, English

Search Terms: “diagnosis” “assessment” “neuropathic” “pain” “cancer” “patients”




18




Records after duplicates removed (n=12)

Records screened (n=12)



(n = 12) 11 – Irrelevant to cancer related neuropathic pain

1 – Involved children

Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text;Biomedical Reference Collection: Comprehensive;MEDLINE Search Terms: “Lidocaine” AND “Neuropathic pain OR Cancer” Filters 10years, Humans, English




articles (n = 14)

What is the evidence for the use of Lidocaine in the management of cancer- related neuropathic pain?


(n=12)


(n = 0 )

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Records after duplicates removed (n = 22)



(n =22)


(n = 20) Irrelevant to cancer

related neuropathic pain


(n = 0 )

Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text;Biomedical Reference Collection: Comprehensive;MEDLINE. Filters 10years, Humans, English

Search Terms: “Scrambler” AND “Neuropathic pain”


Records identified articles (n = 24)

What is the evidence for the use of Scrambler therapy in the management of cancer- related neuropathic pain?

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82 – Irrelevant to cancer related neuropathic pain


(n =2)





(n = 0 )

Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text;Biomedical Reference Collection: Comprehensive;MEDLINE . Filters 10years, Humans, English Search Terms: “Neuropathic pain” OR “Tapendatol” OR “cancer management”




Records identified articles n = 200

What is the evidence for the use of Tapendatol in the management of cancer-related neuropathic pain?

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(n =162 )





(n = 0 )

Searched via EBSCOhost Research Databases Database - Health Business Elite;CINAHL with Full Text;GreenFILE;Library, Information Science & Technology Abstracts;MEDLINE;MEDLINE with Full Text;Biomedical Reference Collection: Comprehensive;MEDLINE Search Terms:“Transcutaneous electrical nerve stimulation” OR “neuropathic pain” OR “cancer related pain” Filters 10years, Humans, English




Records identified articles n = 224

What is the evidence for the use of TENS in the management of cancer-related neuropathic pain?

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Databases searched: Medline PsycINFO and Embase Search Terms: Neuralgia, Neoplasm, Psychological interventions Searches limited to English, Humans and published between 2003 and 2014.

Evidence for the use of psychological intervention for the management of cancer- related neuropathic pain



Reviewers: S Simpson, K Marley

Records identified Medline(n =2 )

Embase (n= 120) PsycINFO (n= 1)

Records screened (n =123)


• Different study

population

• Method of

intervention used.


(n = 3)


(n =3)

• 3 x review

article


(n =0)

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Databases searched: Medline and Embase Search Terms: Neuralgia, antidepressive agents, cancer, neoplasms Searches limited to English, Humans and published between 2003 and 2014.

Evidence for the use of antidepressants for the management of cancer-related neuropathic pain



Reviewers: S Simpson, K Marley

Records identified

Medline(n =8 ) Embase (n= 5)



• 3 duplicates

• 1 case history


(n = 9)


(n =6)

• 1 x prevalence

study

• 5 x review


(n =3)

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Guidelines for the Management of Cancer-related Neuropathic Pain Date of Publication: July 2018


What is the evidence for the use of Opioids in the treatment of cancer-related neuropathic pain?

MEDLINE AND EMBASE, ADULTS, LAST 10years, English Terms used ((pain management) AND cancer patient) OR (cancer pain) OR cancer related pain)) AND (((neuropathy AND pain) OR( neuropathic pain) AND opioid OR opiate) OR (cancer)) AND ((neuropathy AND pain) OR( neuropathic pain)) AND (opioid OR opiate) limited to Cancer/Neoplasms in the MeSH and EMTREE thesauri

Appendix 12: Systematic Review Summary Form Guideline Title: Management of Cancer-related neuropathic pain Reviewers: Esraa Sulaivany and Graham Leng

Records screened (n =75 )


(n = 5)


(n =9)


(n = 4) Non cancer related neuropathic

pain , descriptive only

Records identified (n =75 )

Records excluded (n =66 )

Duplicate=6 Non-specific to neuropathic

pain=17 Cancer treatment related

neuropathic pain=11 Non opioids= 17

Non adult only= 2 Descriptive paper /pain

classification=13

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What is the evidence for the use of steroids in cancer related neuropathic pain?

Appendix 13: Systematic Review Summary Form Guideline Title: Management of Cancer-related neuropathic pain Reviewers: Esraa Sulaivany and Graham Leng



+ reasons why excluded Not neuropathic pain=8

Not steroids =2 Pain classification and

descriptive=3 Treatment related =4


(n =8)


(n =1)

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What is the evidence for the use of clonazepam in cancer related neuropathic pain?

Appendix 14: Systematic Review Summary Form Guideline Title: Management of Cancer related neuropathic pain Reviewers: Esraa Sulaivany and Graham Leng



+ reasons why excluded Non cancer related and

treatment related


(n =2 )


(n =1)

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4. Merseyside and Chesire Palliative Care Network Audit Group Guidelines for the Management of Cancer-related Neuropathic Pain. 2004 Updated 2009 [Link].

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guidelines for the treatment of cancer-related neuropathic pain...neuropathic pain questionnaire are...

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