Quick Links

Share with Colleagues
Previous EBM Focus Issues
DynaMed Free Trial
Send Comment to Editor

Join Our Mailing List



Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: January 28, 2015
Expiration Date: January 28, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237L2

Last week 703 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 149 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Oral and Topical Pharmacological Agents for Neuropathic Pain

Reference: Lancet Neurol 2015 Feb;14(2):162 (level 2 [mid-level] evidence)

Neuropathic pain can be due to disease or damage to the somatosensory nervous system by numerous clinical factors including infection, metabolic disease, trauma, and autoimmune disease (CMAJ 2006 Aug 1;175(3):265, Continuum (Minneap Minn) 2012 Feb;18(1):161). Current estimates suggest that 7-10% of the general population experience chronic neuropathic pain and ineffective treatment is associated with poor physical and mental health, pain-related disability, high health care use, and a high socioeconomic burden (Pain 2014 Apr;155(4):654,Pain 2013 May;154(5):690). Proper pain management is crucial for improving patientsí quality of life, but determining the best treatment can be difficult. A recent systematic review of 229 randomized trials compared oral and topical pharmacological treatments vs. placebo in patients with neuropathic pain. One of the aims of the systematic review was to update the International Association for the Study of Pain/Neuropathic Pain Special Interest Group (IASP/NeuPSIG) guideline on neuropathic pain.

The included trials investigated a wide variety of drugs with different dosages and trial durations. Although these trials included a number of different patient populations, 55% investigated patients with diabetic neuropathy or postherpetic neuralgia. The number needed to treat (NNT) for at least a moderate reduction in pain and the number needed to harm (NNH) (the number needed to treat for 1 patient to drop out due to adverse events) were calculable for 77% of trials and the combined results for each drug or drug class were reported. Most treatments had a moderate effect size, with high to moderate quality of evidence available for several first, second, and third line drugs. All first-line treatment options had an NNT of 9 or less, with the lowest NNT reported for tricyclic antidepressants (4, 95% CI 3-4.4). Serotonin-noradrenaline reuptake inhibitors had an NNT of 7 (95% CI 5.2-8.4), however this drug class was also associated with the highest discontinuation rate of first-line drugs with a NNH of 11. Pregabalin, gabapentin, and gabapentin extended release or enacarbil had NNTs of 8, 7, and 9 respectively, though gabapentins had the lowest NNHs of all drugs reported (25-32). Second-line drugs tramadol and capsaicin 8% patches had moderate to low effect sizes, but only low quality evidence was available for lidocaine patches and the NNT could not be calculated. Evaluated third-line drugs included strong opioids and botulinum toxin A, and although botulinum toxin A had a low NNT, only 4 trials contributed to the analysis.

This systematic review suggests a number of pharmacological agents may provide at least moderate pain relief in patients with neuropathic pain, however there is no one size fits all treatment option.  While NNT numbers suggest most oral medications have a moderate effect size, most were also accompanied by tolerability that was moderate at best, as demonstrated by a low NNH.  These findings are also supportive of recommendations made by the European Federation of Neurological Science (EFNS) with the most notable difference being the systematic review adding capsaicin as a second-line agent and botulinum toxin A as a third-line agent for all patients with neuropathic pain.  One of the persistent areas of uncertainty is whether certain causes of neuropathic pain may respond more favorably, or develop more adverse effects, to specific treatments.  Also, all included trials were performed in adult neuropathic pain populations, so trials in children are needed to determine best therapy in that age group.

For more information, see the Peripheral neuropathy, Diabetic peripheral neuropathy, and Postherpetic neuralgia topics in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

PEMSoft Mobile

Free Trial of PEMSoft Mobile Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCO Health. Designed by pediatricians, emergency physicians and other medical specialists, the vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training