Table 2. Pharmacologic options for NP... | American Society of Hematology

Table 2.

Pharmacologic options for NP treatment

Therapy	2015 Lancet Neurology meta-analysis of treatments for NP^39,*	2020 ASH guidelines for SCD chronic pain without identifiable cause	Interventional studies of NP in SCD?	Considerations
Gabapentinoids (gabapentin, pregabalin)	First line: strong recommendation Best studied NNT = 7.2 (gabapentin) NNT = 7.7 (pregabalin)	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	One completed study (pregabalin): safe, trend toward pain reduction One ongoing (gabapentin) for acute pain	Fatigue and dizziness most common side effects May be intolerable/trigger workup in SCD
Serotonin and norepinephrine reuptake inhibitors	First line: strong recommendation NNT = 6.4	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	• None	• Risk of suicidal ideation in children
Tricyclic antidepressants	First line: strong recommendation NNT = 3.6	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	• None	Risk of suicidal ideation in children Imipramine also used for enuresis
Topical patches (lidocaine 5%, capsaicin 8%)	Second line: weak recommendation NNT = 10.6 (capsaicin) Only for peripheral NP	• Not addressed	• Phase 2 single-arm pediatric study (lidocaine for acute pain): well tolerated, evidence for clinical efficacy
Tramadol	Second line: weak recommendation NNT = 4.7 Least studied of recommended drugs	• Not addressed	• None
Strong opioids	Third line: weak recommendation NNT = 4.3 Third line due to abuse and adverse effect potential	• Current standard, no robust comparison studies found between chronic opioid and nonopioid treatment	• None for neuropathic pain	• Difficult to replace due to unique interplay between acute and chronic pain, nociceptive pain and NP
Ketamine	• Inconclusive evidence	Oral ketamine: not addressed IV ketamine (for refractory acute pain): conditional recommendation based on very low certainty in evidence	• Studied for VOC/acute pain treatment with demonstrated benefit	• Not mentioned by either resource but used for acute SCD pain and for NP in separate studies
Trifluoperazine	• Not addressed	• Not addressed	• Phase 1 open label study: safe, evidence of efficacy

Therapy	2015 Lancet Neurology meta-analysis of treatments for NP^39,*	2020 ASH guidelines for SCD chronic pain without identifiable cause	Interventional studies of NP in SCD?	Considerations
Gabapentinoids (gabapentin, pregabalin)	First line: strong recommendation Best studied NNT = 7.2 (gabapentin) NNT = 7.7 (pregabalin)	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	One completed study (pregabalin): safe, trend toward pain reduction One ongoing (gabapentin) for acute pain	Fatigue and dizziness most common side effects May be intolerable/trigger workup in SCD
Serotonin and norepinephrine reuptake inhibitors	First line: strong recommendation NNT = 6.4	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	• None	• Risk of suicidal ideation in children
Tricyclic antidepressants	First line: strong recommendation NNT = 3.6	Conditional recommendation based on very low certainty in evidence Recommendation for adults only	• None	Risk of suicidal ideation in children Imipramine also used for enuresis
Topical patches (lidocaine 5%, capsaicin 8%)	Second line: weak recommendation NNT = 10.6 (capsaicin) Only for peripheral NP	• Not addressed	• Phase 2 single-arm pediatric study (lidocaine for acute pain): well tolerated, evidence for clinical efficacy
Tramadol	Second line: weak recommendation NNT = 4.7 Least studied of recommended drugs	• Not addressed	• None
Strong opioids	Third line: weak recommendation NNT = 4.3 Third line due to abuse and adverse effect potential	• Current standard, no robust comparison studies found between chronic opioid and nonopioid treatment	• None for neuropathic pain	• Difficult to replace due to unique interplay between acute and chronic pain, nociceptive pain and NP
Ketamine	• Inconclusive evidence	Oral ketamine: not addressed IV ketamine (for refractory acute pain): conditional recommendation based on very low certainty in evidence	• Studied for VOC/acute pain treatment with demonstrated benefit	• Not mentioned by either resource but used for acute SCD pain and for NP in separate studies
Trifluoperazine	• Not addressed	• Not addressed	• Phase 1 open label study: safe, evidence of efficacy

NNT, number needed to treat.

The Lancet Neurology meta-analysis was selected for simplicity as being representative of broader NP recommendations from the pain literature (which do not include SCD). American Society of Hematology guidelines for chronic pain are based on indirect evidence from patients with fibromyalgia.

View Large

This Feature Is Available To Subscribers Only