Neuropathic Pain
Red Flags — neuropathic pain presentations requiring urgent action
| Red flag | Concern | Action |
|---|---|---|
| Cauda equina features — saddle numbness + bladder/bowel | Cord compression causing neuropathic pain as presenting feature. Any perianal or perineal neuropathic pain + bladder/bowel change: 999. Emergency MRI. | 999 / same-day A&E — emergency MRI |
| Rapidly ascending weakness + sensory loss (GBS pattern) | Guillain-Barré syndrome: ascending weakness + sensory loss; ascending from feet; neuropathic pain as precursor; respiratory failure risk. Medical emergency. | 999 — hospital admission; respiratory monitoring; IVIG |
| Neuropathic pain in known cancer patient + new back pain | Spinal cord or nerve root compression from metastases. Urgent MRI full spine. Dexamethasone 8mg if cord compression suspected. | Same-day urgent MRI; dexamethasone; oncology |
| Shingles (VZV rash) — within 72 hours of onset | Antiviral treatment (aciclovir or valaciclovir) within 72 hours of rash reduces severity and PHN risk. After 72 hours: antivirals less effective but may still help if new lesions forming. | Antiviral within 72h; adequate analgesia; ophthalmology if eye involvement |
| Rapidly progressive or asymmetric neuropathy | Vasculitis; CIDP; sarcoidosis; malignancy-associated. Multiple nerve territories; constitutional features. Urgent neurology. | Urgent neurology — NCS; vasculitis screen; ANCA; ESR |
Safeguarding — Chronic Pain, Depression, and Vulnerability in Mrs. Osei
💕 Suicidality — PHQ-9 Q9
- PHQ-9 Q9 specifically: ask about suicidal ideation at this consultation and at 2-week review after antidepressant initiation
- If Q9 ≥1: urgent mental health assessment regardless of total score
- Amitriptyline: low therapeutic index — if any suicidality concern: supply restrict to 2-week prescriptions; prefer duloxetine (slightly safer in overdose)
- All antidepressants: increased suicidal ideation risk in first 4 weeks — document safety-net given
🏠 Social isolation and elder vulnerability
- Unable to walk — main social activity lost; progressive isolation; depression worsening
- Ask: who does she live with? Social support? Community activities?
- Social prescribing: pain support groups; befriending services; adapted exercise
- Elder financial abuse: chronic illness increases vulnerability; if any concern about finances or home situation: social services referral
📈 Diabetes self-management
- Depression reduces diabetes self-management (medication adherence; dietary control; exercise)
- PHQ-9 ≥10 independently predicts poor diabetes outcomes — treating depression is treating diabetes
- Poor sleep from pain → raised cortisol → worsened glucose control → worse neuropathy — a vicious cycle
- Refer to diabetes nurse specialist for holistic support
💋 Medication safety
- Gabapentinoids: Schedule 3 CD; misuse potential; sedation increases fall risk in elderly
- Amitriptyline: dangerous in overdose (QRS widening; arrhythmia); prescribe 2-week supply if depression + suicidality concern
- Do not prescribe strong opioids for neuropathic pain in an elderly patient with depression — addiction and overdose risk
📈 Fear of DM Progression
Mrs. Osei interprets her pain as evidence that diabetes is “getting worse.” This catastrophic belief amplifies pain through central sensitisation. Must be directly addressed: DPN is caused by long-term hyperglycaemia; the pain is the nerve’s response; HbA1c optimisation prevents further damage; pain does not mean imminent amputation.
"The pain in your feet is a complication of diabetes — it means the nerves are irritated by years of raised blood sugar. This doesn’t mean your diabetes is out of control — it means we need to manage it better and treat the nerve pain directly."💔 Amputation Fear
Mrs. Osei’s friend had a diabetic amputation. This is a powerful fear she is likely carrying. Amputation occurs from infected foot ulceration — not from neuropathic pain per se. Naming this fear, correcting it with accurate information, and offering podiatry referral as active prevention is both reassuring and clinically appropriate.
"I want to address what I think may be worrying you. Amputations in diabetes happen when there is a wound that doesn’t heal — because of poor circulation. You don’t have that right now. The podiatrist will help us keep a close eye on your feet."😴 Sleep and Pain Cycle
Night pain → poor sleep → reduced endogenous pain inhibition → more pain. Amitriptyline at night addresses both pain and sleep. If duloxetine chosen (morning dosing; may cause insomnia): add low-dose amitriptyline 10mg at night for sleep benefit if needed.
"Has the pain been waking you up? Poor sleep and pain have a difficult relationship — they make each other worse. One reason I am choosing this particular medication is that it also helps with sleep when taken at night."💓 Loss of Identity and Activity
Daily walking was Mrs. Osei’s primary physical and social activity. Its loss worsens depression, isolation, and pain. Adapted exercise (swimming; chair yoga; short walks to tolerance) replaces what can be replaced. Exercise is both analgesic and antidepressant.
"I know not being able to walk has taken a lot from you — not just the physical health but everything that came with it. Let’s see if we can get you to some adapted exercise while the treatment gets to work."- Prescribing stronger opioids without explaining why current drugs fail — opioids are not first-line for neuropathic pain and miss the mechanism
- Not acknowledging Mrs. Osei’s distress before clinical questions
- Not addressing the amputation fear if it emerges
999 / Same-Day Hospital
Immediate- Cauda equina syndromeSaddle numbness + bladder/bowel; 999; emergency MRI
- Guillain-Barré syndromeAscending weakness; respiratory risk; 999; IVIG
- Cord compression — cancer patient + back painSame-day; dexamethasone; urgent MRI
Urgent Referral
Days to 2 weeks- Shingles — within 72h of rashAntiviral (aciclovir/valaciclovir); ophthalmology if eye
- Rapidly progressive or atypical neuropathyNeurology; NCS; vasculitis screen; ANCA
Primary Care
NICE CG173- Diabetic peripheral neuropathy — Mrs. OseiDuloxetine first; HbA1c optimisation; podiatry
- Post-herpetic neuralgiaAmitriptyline; gabapentinoid; lidocaine patches
- Trigeminal neuralgiaCarbamazepine; neurology if refractory
- Not screening for cauda equina features in a patient with lower limb neuropathic pain
- Not inspecting the feet in a diabetic patient with foot neuropathic pain — an active ulcer must be excluded before an outpatient plan; missed diabetic foot ulcer is a significant patient safety event
- Prescribing gabapentin or pregabalin without checking eGFR first — mandatory; prescribing standard dose with eGFR <60 = prescribing error
"Your pain is coming from the nerves in your feet. When blood sugar is slightly high over many years, it gradually damages the fine nerve endings. When nerves are damaged, they become irritated and send pain signals even when nothing is actually hurting the foot — like a fire alarm that keeps going off when there is no fire. That is why you feel burning; shooting pain; electric shocks — these are the damaged nerves misfiring. This is called diabetic peripheral neuropathy. It is a recognised complication of diabetes and it is treatable — though I want to be honest: we aim for a significant improvement, not necessarily complete elimination of the pain. The reason paracetamol and ibuprofen have not helped is that they treat a completely different kind of pain — tissue damage and inflammation. Your pain is not from tissue damage; it is from irritated nerves firing abnormally. The drugs that work for nerve pain are completely different."
"Does this mean I am going to lose my feet?"
"I want to address that directly, because I think it may be worrying you. Amputations in diabetes happen when there is a wound or injury to the foot that doesn’t heal — usually because of poor circulation and infection. The nerve pain you have is different: it is a sign that the nerves are irritated, not that you are about to lose your feet. You don’t have any foot wounds right now — and the most important thing we can do together to prevent problems is to make sure your feet are looked after properly. I am referring you to the podiatrist today."
"Why haven’t my painkillers worked?"
"Paracetamol and ibuprofen work by reducing inflammation and blocking the chemical signals of normal tissue damage pain. But your pain is not from tissue damage — it is from nerves misfiring. These drugs act on completely the wrong pathway. The tablets I am going to prescribe today work specifically on the nerve pain pathways — in the spinal cord — where they can quiet down the misfiring signals."
Setting treatment expectations
"I want to be honest with you about what the medication can achieve. We aim for a reduction of at least 30 to 50 percent in your pain. If you are at 8 out of 10 now, the target is 4 out of 10. I know that doesn’t sound like complete relief — but most patients find that level of improvement makes an enormous difference to their sleep; their ability to walk; their mood; their quality of life. The tablets take 4 to 8 weeks to work at the right dose. Please do not stop them at 2 weeks if you still have some pain."
B12 deficiency neuropathy
Metformin-related. Check B12; replace if <150 pg/mL. Can coexist with DPN.
Hypothyroid neuropathy
Check TFTs; treatment may reverse neuropathy.
Active foot ulcer
Foot inspection: no active ulcer documented today. Podiatry referral made.
Cauda equina; GBS
Not present: no bladder/bowel change; no ascending weakness. Documented.
- Not setting treatment expectations (30–50% reduction; 4–8 weeks) — the patient who is not told this will stop the medication at 2 weeks if they still have some pain
- Not correcting the amputation illness model when it emerges
- Not referring to podiatry in a diabetic patient with neuropathy and possible protective sensation loss — NICE quality standard; significant clinical omission
Validate — the frustration is earned
Three months of pain; three months of ineffective tablets; three months of lost sleep. The frustration is rational.
"I completely understand the frustration — you have been taking tablets every day for 3 months that haven’t helped. And I want to explain why they haven’t worked, and what we are going to do differently — because there are drugs that do work for this type of pain."Explain the mechanism difference specifically
A patient who understands why the new drug is different will persist through the titration period. One who simply receives a new prescription without explanation will stop it at 2 weeks.
"Paracetamol and ibuprofen work on inflammation and prostaglandins — the chemical signals of tissue damage pain. But your pain is coming from damaged nerves that are misfiring — not from tissue damage. The new tablet works on the nerve pain pathways in your spinal cord — it is a completely different mechanism. That is why I am not prescribing a stronger version of what you have been taking."Set honest expectations — 30–50% reduction; 4–8 weeks
The patient who is promised complete pain relief will be disappointed. The patient who is promised significant improvement with a realistic timeframe will be better equipped to persist.
"This drug takes 4 to 8 weeks to work at the right dose. The target is to get your pain from 8 out of 10 down to 4 out of 10. I know that’s not complete relief — but most people find that level of improvement makes an enormous difference to their sleep; their ability to walk; their mood. I will review you in 4 weeks to see how it is going."Protective sensation loss means Mrs. Osei may not feel a foot injury. A small wound that goes unnoticed can become a large ulcer, then infected, then a potential amputation trigger. Daily foot inspection is the single most effective intervention for preventing diabetic foot complications — and teaching it today is as important as the prescription.
Inspect both feet daily with a mirror for the soles. Check between toes. Report any redness; wound; blister; or colour change immediately. Well-fitting cushioned shoes at all times. Never walk barefoot. Moisturise dry skin (not between toes). No home corn or callus treatment — podiatrist only.
Exercise is analgesic (endorphins; descending inhibitory activation); improves HbA1c; reduces depression. Mrs. Osei has stopped her daily walks — this worsens both pain and depression. Adapted exercise preserves function and breaks the deconditioning cycle. Social prescribing: exercise on prescription; chronic pain exercise groups.
Short walks (5–10 min); increase as pain allows. Swimming: excellent (unloads feet; aerobic; social). Chair-based yoga or stretching. Exercise on prescription referral. Goal: “Can you walk to the end of the road and back this week?”
CBT + pharmacological treatment is more effective than pharmacology alone for chronic neuropathic pain with comorbid depression. Acceptance and Commitment Therapy (ACT): values-based living despite pain — particularly effective. NHS Talking Therapies: Low or High Intensity CBT depending on PHQ-9 severity.
NHS Talking Therapies self-referral or GP referral. Online CBT (SilverCloud; Beating the Blues). Pain management programme referral if NHS Talking Therapies inadequate. Set expectation: CBT takes 6–12 weeks; works best alongside medication.
Night pain → sleep disruption → reduced endogenous pain inhibition → more pain. Treating sleep is a pain intervention. Amitriptyline at night addresses both. If duloxetine chosen (morning dosing; may cause insomnia): add low-dose amitriptyline 10mg at night for sleep if needed.
Regular sleep/wake times. Avoid caffeine after 2pm. Cool; dark bedroom. No screens before bed. Progressive muscle relaxation. Sleep restriction therapy if chronic insomnia. Duloxetine in the morning; amitriptyline at 10pm if used.
Patients who understand their condition — the mechanism; the rationale for treatment; the timeline; self-management — have better outcomes. Mrs. Osei needs to understand: why NSAIDs fail; what duloxetine does; when to expect benefit; foot care; when to seek help urgently.
Diabetes UK foot care guide (diabetes.org.uk). Pain Concern helpline: 0300 123 0789. NHS chronic pain leaflet. Living Well with Persistent Pain: persistent-pain.readingwell.org.uk. NHS Talking Therapies leaflet + self-referral if PHQ-9 ≥10.
HbA1c optimisation is the only disease-modifying intervention for DPN. Prevents further progression (DCCT; UKPDS). Mrs. Osei HbA1c 62 (target <53): medication review via diabetes team. SGLT2 inhibitors: also cardiovascular + renal protection — important in DPN (cardiovascular risk marker). Note: rapid glucose improvement can transiently worsen DPN (acute painful neuropathy of rapid control; rare but recognised — warn).
Diabetes team referral today. Mediterranean diet; reduced refined carbohydrate. Weight management. Regular glucose monitoring. Annual diabetes review: HbA1c; renal function; retinopathy; neuropathy; cardiovascular risk.
- 30mg OD with food for 1 week; increase to 60mg OD at week 2
- Licensed for DPN (NICE CG173 first-line); dual indication if PHQ-9 ≥10
- 4–8 weeks for full analgesic and antidepressant effect
- Monitor BP at 4 weeks; PHQ-9 at 2 weeks and 4 weeks; LFTs at 3 months
- Taper over minimum 4 weeks on discontinuation (avoid discontinuation syndrome)
- 10mg OD at night; titrate by 10mg every 2 weeks; target 25–50mg
- Sleep benefit (sedating at low dose) — particularly useful for Mrs. Osei’s night pain
- Check ECG first (age 67; DM; QTc risk)
- Supply restrict to 2-week supply if PHQ-9 ≥10 (overdose risk; low TI)
- Anticholinergic: dry mouth; constipation; urinary retention; fall risk
- Tramadol or strong opioids: NOT first-line for neuropathic pain (NICE CG173); harms exceed benefits; do not correct the nerve mechanism
- NSAIDs or paracetamol alone: ineffective for pure neuropathic pain; NSAIDs worsen nephropathy in DM — stop ibuprofen today
- Gabapentinoid without checking eGFR: mandatory safety check; prescribing standard dose with eGFR 35 = prescribing error
- Carbamazepine: first-line for TN only; not for DPN or other neuropathic pain
- Gabapentin: 300mg OD day 1; 300mg BD day 2; 300mg TDS day 3; titrate to 1800–3600mg/day; Schedule 3 CD; check eGFR first
- Pregabalin: 75mg BD; titrate to 150mg BD; max 300mg BD; Schedule 3 CD; also licensed for GAD
- BOTH: 50% dose reduction if eGFR 30–59; 75% if eGFR 15–29
- Sedation; dizziness; weight gain; fall risk in elderly; taper on discontinuation
- Lidocaine 5% plasters (Versatis): PHN only; 1–3 plasters; 12h on / 12h off; intact skin; minimal systemic absorption; safe in elderly
- Capsaicin 0.075% cream: 3–4 times/day; initial burning; deplete substance P; 4–6 weeks for effect
- Capsaicin 8% (Qutenza): specialist clinic only; single application; up to 3 months relief
Select patient characteristics — neuropathic pain drug guidance
"I am prescribing a tablet called duloxetine. It works on the nerve pain pathways in your spinal cord — completely different from paracetamol or ibuprofen. It also helps with your mood. Start with 30mg once a day with food for a week, then move up to 60mg. It takes 4 to 8 weeks to feel the full benefit — please don’t stop it at 2 weeks if you still have some pain. I will review you at 4 weeks."
Duloxetine 30mg OD → 60mg OD: NICE CG173 first-line for DPN; dual indication with PHQ-9 ≥10; avoid if eGFR <30 or severe hepatic impairment. 4–8 weeks for effect; taper on discontinuation; monitor BP + PHQ-9. SCA key: choosing duloxetine for Mrs. Osei (DPN + PHQ-9 12) demonstrates understanding of the dual indication — distinguishes strong pass from bare pass.
"Take this at around 10 at night — it will help with the nerve pain and also helps with sleep, which is very useful because the pain is worst at night. You may feel a bit drowsy the next morning at first — that usually improves. Your mouth may feel dry. Do not drive until you know how it affects you."
Amitriptyline: NICE CG173 first-line; all neuropathic types; 10mg OD night; titrate to 25–50mg; ECG before in cardiac-risk patients. SUPPLY RESTRICT to 2-week supply if PHQ-9 ≥10 (low therapeutic index — dangerous in overdose). Anticholinergic: dry mouth; fall risk. Can combine with duloxetine (additive mechanism) if single agent insufficient.
"This is a controlled drug that we start at a low dose and build up slowly over a few weeks. It may make you drowsy at first — do not drive until you know how it affects you. It can cause weight gain. If we ever need to stop it, we do so gradually — never all at once."
Gabapentin: NICE CG173 first-line for neuropathic pain; Schedule 3 CD; check eGFR BEFORE prescribing; dose-reduce at eGFR <60; taper on discontinuation. KEY DISTINCTION: gabapentin IS first-line for neuropathic pain (CG173) but NOT recommended for non-specific LBP (NG59) — tested frequently; getting this backwards is a common SCA error.
"This is a controlled drug — similar to gabapentin but twice-a-day dosing and a simpler schedule. It can make you drowsy — do not drive until used to it. We taper it gradually when stopping."
Pregabalin: NICE CG173 first-line; Schedule 3 CD; faster titration than gabapentin; check eGFR before prescribing (same renal dose adjustments); also licensed for GAD. Never prescribe for non-specific LBP (NICE NG59). Misuse potential: higher euphoria rate; caution in addiction history.
"These patches contain a local anaesthetic. Apply them to the painful area for 12 hours — usually overnight — and remove them for the next 12 hours. Use up to 3 at a time. Only put them on skin that is not broken or irritated. They work at the nerve endings with minimal effect on the rest of your body."
Lidocaine 5% plasters (Versatis): PHN specific; 1–3 plasters; 12h on / 12h off; intact skin; minimal systemic absorption; safe in elderly (no sedation; no fall risk). Not for DPN (Mrs. Osei’s condition). Particularly useful for allodynia. High-strength capsaicin 8% (Qutenza): specialist clinic; highly effective for PHN.
"This tablet is very effective for the type of facial pain you have. We start low and build up. I will do blood tests to monitor your blood count and salt levels. Tell me immediately if you develop a sore throat; a fever; or a rash — because rarely this drug can affect the blood, and that needs prompt attention."
Carbamazepine: FIRST-LINE for trigeminal neuralgia ONLY — not DPN; not PHN. 100mg BD → titrate. Monitor Na+ (SIADH); FBC (agranulocytosis — report fever/sore throat; urgent FBC); LFTs; drug interactions (CYP450 inducer). Neurology if refractory; MVD surgery potentially curative. SCA: prescribing amitriptyline or gabapentin as first-line for TN = Tasks fail.
Driving
Sedating medications must be discussed. Amitriptyline: initial sedation; do not drive until established on dose. Gabapentinoids: significant sedation; warn specifically. Duloxetine: less sedating but warn about initial period. DVLA: if medication impairs driving ability the patient must not drive — legal obligation. Document driving advice in notes.
"I need to mention — this medication can make some people drowsy at first. Until you know how it affects you, please do not drive. If you find it is making you drowsy when driving, you must stop using the car — it is a legal as well as a safety requirement."Social Life and Isolation
Mrs. Osei’s daily walk was her primary social and physical activity. Its loss has isolated her — worsening depression and pain. Social prescribing: chronic pain groups; telephone befriending; adapted exercise classes. The duloxetine will help mood; any restored mobility breaks the isolation cycle.
"I want to think about getting you back to some social contact too. The pain can become very isolating. There are local groups for people managing persistent pain — I can refer you through our social prescribing service."Relationships and Intimacy
Chronic pain and medication side effects (duloxetine: sexual dysfunction; amitriptyline: same) affect intimacy. The GP who opens this conversation removes the stigma. Information that medications may affect this — and alternatives exist — is practically important.
"Chronic pain can sometimes affect other parts of life — including intimacy with a partner. Is that something that has been a concern? The medication can sometimes affect this too — please let me know if it becomes an issue."Sleep
Night pain worsens sleep; poor sleep amplifies pain. If duloxetine chosen (morning dosing; may cause insomnia): add low-dose amitriptyline 10mg at night for sleep benefit if needed. Sleep hygiene alongside pharmacological treatment.
"Has the pain been waking you? Poor sleep and pain make each other worse. One reason I am considering the nighttime tablet option is that it also helps sleep — which is part of the pain treatment."Diabetes Anxiety
Mrs. Osei interprets her pain as evidence of diabetes deteriorating. This catastrophic belief amplifies pain. It must be directly corrected: DPN does not mean imminent amputation; HbA1c optimisation prevents progression; foot care prevents ulceration. Anxiety about diabetes is a driver of depression and pain — addressing the illness model is a pain intervention.
"I want to be clear — this pain does not mean your diabetes is about to cause you to lose your feet. It means the nerves are irritated. With the right treatment and foot care, we can manage this well."Identity and Loss
Retired teacher; active; community-connected — chronic pain threatens this identity. The loss of daily walks removes a key source of independence and self-efficacy. Adapted exercise (chair yoga; swimming) and community groups restore what can be restored alongside pain management.
"I can see this has taken a lot from you — not just the pain, but the walking and the activities. I want us to work together to get you back to as much of that as possible. The medication is the start — not the end."Today — Duloxetine 30mg OD; stop ibuprofen; investigations; referrals; safety-nets given
Duloxetine 30mg OD food; increase to 60mg OD at week 2. Ibuprofen stopped (ineffective + nephropathy risk). eGFR; B12; HbA1c; LFTs; ECG requested. PHQ-9 12; Q9 screened; suicidality safety-net given and documented. Podiatry referral. Diabetes team referral. NHS Talking Therapies referral. Foot care education provided. Driving advice given. DN4 scored and documented. 4-week review booked.
2 Weeks — PHQ-9 suicidality check; duloxetine tolerability; dose increase confirmed
Telephone or face-to-face. Is she tolerating duloxetine? Has nausea settled? Has she been able to increase to 60mg OD? PHQ-9 at 2 weeks (mandatory suicidality monitoring with antidepressant initiation). If Q9 ≥1: urgent face-to-face. Driving status confirmed.
4 Weeks — Main review: pain NRS; PHQ-9; DN4; blood results; foot inspection
Face-to-face. NRS pain: ≥30% improvement? PHQ-9: improvement from 12? DN4 re-score. Review bloods. Foot inspection. If ≥30% improvement: continue duloxetine 60mg. If <30%: titrate to 90–120mg (check BP; specialist territory) OR add amitriptyline 10mg at night. If no improvement: switch to gabapentinoid (check eGFR allows dose). Podiatry + diabetes team updates expected.
8–12 Weeks — Second agent or pain clinic if needed
If duloxetine 60mg at 8 weeks: inadequate response — add amitriptyline 10mg OD at night OR switch to gabapentinoid (eGFR first). If second agent also inadequate: pain clinic referral. HbA1c review from diabetes team. Annual podiatry. NHS Talking Therapies progress.
Annually — DPN; diabetes; mental health; podiatry
Annual diabetes foot check (NICE quality standard). PHQ-9 + GAD-7. NRS pain score. Medication review. eGFR. HbA1c. Retinopathy screening. Pain clinic if complex or refractory.
SNAP monitoring mnemonic for neuropathic pain
Sleep: improved? Sleep quality as proxy for pain control. NRS: 0–10 pain score at every review — ≥30% improvement? Activity: can Mrs. Osei walk further; do more than at first visit? PHQ-9: depression score at every review — pain and depression must be tracked together.
⚠ Three critical safety-nets for Mrs. Osei
Documentation requirements
- Prescribing tramadol or opioids as the next step — not first-line for neuropathic pain; treats the wrong mechanism
- Prescribing gabapentinoid without checking eGFR — mandatory safety check
- Not explaining why NSAIDs and paracetamol failed — without this explanation Mrs. Osei has no reason to persist with a different drug
- Not setting the 30–50% reduction expectation over 4–8 weeks — will lead to premature discontinuation
- Not addressing the amputation fear — the most likely hidden concern; leaving it unresolved
- Not checking PHQ-9 Q9 suicidality when initiating an antidepressant with PHQ-9 12
- Carbamazepine as first-line for DPN — carbamazepine is for TN only
- DPN diagnosed; DN4 scored; mechanism explained
- PHQ-9 12; Q9 suicidality screened; documented
- Duloxetine prescribed (dual indication; correct dose; titration plan)
- NSAIDs stopped with rationale
- eGFR checked (before prescribing; even if gabapentinoid not chosen)
- Podiatry + diabetes team + NHS Talking Therapies referred
- 4-week review booked; expectations set
- Distress acknowledged first
- Why NSAIDs fail — plain language explanation
- Amputation fear raised and addressed directly
- 30–50% expectation set honestly
- Depression dual-treatment explained
- Antidepressant suicidality safety-net
- Driving advice given
Who you are
Patricia Osei, 67, retired secondary school teacher (English). Type 2 diabetes for 12 years; HbA1c 62 at last check 3 months ago; on metformin 1g BD and sitagliptin 100mg OD. Bilateral burning foot pain for 6 months, worse at night, stopping sleep. “Like walking on hot coals” with intermittent electric shock sensations. Cannot do daily walks any more — used to walk 45 minutes every morning. Tearful, frustrated, not sleeping properly. PHQ-9 12.
Hidden agenda — disclose if GP creates space
Amputation fear (disclose if GP asks about your worries specifically): “The thing is — my friend Margaret had diabetes and she lost her foot. I’m frightened that is where this is heading. I haven’t wanted to say it but that’s what worries me most.” Respond well if GP explains the difference between DPN and foot ulceration: “Oh — I didn’t realise they were different things. That is actually very reassuring.”
Self-blame (disclose if asked about how you feel about your diabetes): “I feel like I should have managed my diabetes better. Maybe if I’d been stricter about my diet this wouldn’t have happened.” Respond well if GP addresses this without blame: “Thank you for saying that — I’ve been carrying a lot of guilt.”
Sleep desperation (volunteer if asked about impact): “I am not sleeping properly. The pain wakes me up at 2 or 3 in the morning. I am exhausted.”
Responses to key conversations
- On why NSAIDs fail: initially surprised: “But they’re painkillers — I thought that meant they worked on any pain?” — respond well if GP explains the mechanism: “I hadn’t thought of it like that — so there are different types of pain?”
- On duloxetine being an “antidepressant”: may be reluctant: “I don’t want to take an antidepressant — I don’t think I’m depressed.” — respond well if GP explains dual indication: “So it works on the nerve pain as well? Not just the mood? OK, I am more comfortable with that.”
- On treatment timeline: concerned: “4 to 8 weeks — that seems a long time to still be in pain.” — respond well if GP acknowledges this and explains why: “I suppose if it’s actually going to work properly that is worth waiting for.”
- On stopping the ibuprofen: initially worried: “But won’t that leave me with nothing for the pain?” — respond well if GP explains why and the new mechanism: “OK — if it’s not doing anything anyway and it could affect my kidneys, there’s not much point taking it.”
Clinical details
- Age 67; bilateral burning feet ×6 months; worse at night; DN4 score ≥4 (burning; electric shocks; pins and needles; touch sensitivity)
- Paracetamol 1g QDS + ibuprofen 400mg TDS ×3 months — no benefit
- PHQ-9 12 (moderate depression); Q9 = 0 (no suicidal ideation at this appointment)
- Monofilament: reduced protective sensation bilaterally (2–3 sites per foot)
- Foot inspection: no active ulcer; mild dry skin; no callus requiring urgent podiatry
- DM ×12y; HbA1c 62; metformin 1g BD; sitagliptin 100mg OD; no cardiac history
- eGFR: will come back as approximately 68 mL/min/1.73m² (mildly reduced; no dose adjustment needed for standard duloxetine)
Resolution: Mrs. Osei accepts the plan if the GP: explains why paracetamol and ibuprofen do not work for nerve pain (not dismissed but explained specifically); prescribes duloxetine with a clear explanation of both why it helps pain AND mood; addresses the amputation fear directly; sets honest expectations (30–50% reduction over 4–8 weeks); and refers to podiatry and the diabetes team. She leaves saying: “I hadn’t realised there were drugs specifically for nerve pain. And knowing that it’s not necessarily going to end up like what happened to Margaret — that is the most reassuring thing you’ve said today.”
- CES: saddle numbness + bladder/bowel → 999 + emergency MRI
- GBS: ascending weakness + sensory loss → 999 + hospital + IVIG
- Cord compression (cancer) → same-day + dexamethasone
- Shingles <72h of rash → antiviral; ophthalmology if eye
- Rapidly progressive or asymmetric neuropathy → neurology; NCS; vasculitis screen
- DPN (Mrs. Osei): DN4 ≥4; duloxetine or amitriptyline; eGFR; HbA1c; podiatry
- PHN: amitriptyline; gabapentinoid; lidocaine patches; capsaicin
- TN: carbamazepine (NOT amitriptyline/gabapentin first-line)
| SNAP | Parameter | Timing | Action |
|---|---|---|---|
| S — Sleep | Sleep quality; hours; pain awakenings | Every review | Not improving: consider adding amitriptyline 10mg at night (if duloxetine chosen). Sleep hygiene education. |
| N — NRS | Pain score 0–10; DN4 re-score | Every review; DN4 at 4 weeks | <30% improvement at 8 weeks on adequate dose: second agent or pain clinic. ≥30%: continue; optimise. |
| A — Activity | Walking distance; function; activities restored | Every review | No functional improvement: NHS Talking Therapies; adapted exercise prescription; social prescribing. Assess for fear avoidance. |
| P — PHQ-9 | PHQ-9 total; Q9 suicidality specifically | 2 weeks (antidepressant initiation); then every review | Q9 ≥1: urgent mental health assessment. PHQ-9 not improving: review NHS Talking Therapies engagement; increase antidepressant dose; psychology referral. |