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Guideline Summary
Guideline Title
Neuropathic pain. The pharmacological management of neuropathic pain in adults in non-specialist settings.
Bibliographic Source(s)
Centre for Clinical Practice. Neuropathic pain. The pharmacological management of neuropathic pain in adults in non-specialist settings. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 155 p. (Clinical guideline; no. 96).  [122 references]
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Neuropathic pain conditions

Guideline Category
Counseling
Management
Treatment
Clinical Specialty
Endocrinology
Family Practice
Infectious Diseases
Internal Medicine
Neurology
Oncology
Pharmacology
Psychiatry
Psychology
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Patients
Pharmacists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)

To provide clear recommendations to healthcare professionals in non-specialist settings on the treatment and management of neuropathic pain; this includes recommendations on appropriate and timely referral to specialist pain services and/or condition-specific services

Target Population

Adults (aged 18 or over) in primary care and secondary care, excluding specialist pain management clinics, including:

  • Adults with neuropathic pain conditions
  • Subgroups of older people with post-herpetic neuralgia or painful diabetic neuropathy

Note: The following groups will not be covered in this guideline:

  • Adults with neuropathic pain conditions that are managed in specialist pain management clinics
  • Adults with neuropathic pain arising directly from trauma or orthopaedic surgical procedures
Interventions and Practices Considered

Treatment

  1. Key principles of care
    • Patient referral to specialist care
    • Continuation of effective management
    • Potential benefits and harms of pharmacological treatment options
    • Non-pharmacological treatment options
    • Withdrawing and switching treatment
    • Monitoring efficacy and side effects
  2. First-line treatment
    • Amitriptyline
    • Pregabalin
    • Duloxetine
    • Imipramine
    • Nortriptyline
  3. Second-line treatment, depending on first-line treatment
    • Pregabalin
    • Amitriptyline
    • Imipramine
    • Nortriptyline
  4. Third-line treatment, depending on second-line treatment
    • Tramadol
  5. Other pharmacological treatments
Major Outcomes Considered
  • Patient-reported global improvement in symptoms
  • Patient-reported pain relief
  • Patient-reported improvement in daily physical and emotional functioning, including sleep
  • Major adverse effects (defined as leading to withdrawal from treatment), and minor adverse effects of the medication
  • Overall improvement in quality of life
  • Resource use and costs

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Literature Search

The evidence reviews used to develop the guideline recommendations were underpinned by systematic literature searches, following the methods described in 'The guidelines manual' (2009). The purpose of systematically searching the literature is to attempt to comprehensively identify the published evidence to answer the key clinical questions developed by the Guideline Development Group (GDG) and Short Clinical Guidelines Technical Team.

The search strategies for the key clinical questions were developed by the Information Services Team with advice from the Short Clinical Guidelines Technical Team. Structured clinical questions were developed using the PICO (population, intervention, comparison, outcome) model and were translated into search strategies using subject heading and free text terms. The strategies were run across a number of databases with no date restrictions imposed on the searches.

The following sources were searched:

  • Clinical Trials.gov
  • Current Controlled Trials
  • Cochrane Database of Systematic Reviews – CDSR (Wiley)
  • Cochrane Central Register of Controlled Trials – CENTRAL (Wiley)
  • Database of Abstracts of Reviews of Effectiveness – DARE (Wiley)
  • Health Technology Assessment Database – HTA (Wiley)
  • CINAHL (EBSCO)
  • EMBASE (Ovid)
  • MEDLINE (Ovid)
  • MEDLINE In-Process (Ovid)
  • National Research Register Archive
  • UK Clinical Research Network

Economic Literature Search

To identify economic evaluations, the National Health Service (NHS) Economic Evaluation Database (NHS EED) and the Health Economic Evaluations Database (HEED) were searched. Search filters to identify economic evaluations and quality of life studies were used to interrogate bibliographic databases. There were no date restrictions imposed on the searches.

In addition to the systematic literature searches, the GDG was asked to alert the Short Clinical Guidelines Technical Team to any additional evidence, published, unpublished or in press, that met the inclusion criteria.

The searches were undertaken between October and May 2009. Full details of the systematic search, including the sources searched and the MEDLINE strategies for each evidence review, are presented in Appendix 9.7 in the full version of the guideline.

Health Economics Search Strategy

The health technology assessment (HTA) report focused on two neuropathic pain populations: people with post-herpetic neuralgia (PHN) and people with painful diabetic neuropathy (PDN). A systematic review of the economic evidence was also performed as part of the evidence review for this guideline. A systematic search found a total of 2,273 papers. Full details on the search strategy can be found in Appendix 9.7 in the full version of the guideline.

For the purposes of this guideline, the GDG decided at the outset that neuropathic pain would be treated as a 'blanket condition' where possible or necessary. However, it was clear that the treatment of various subpopulations would differ considerably and that it would not be possible to extrapolate from one subgroup to all people with neuropathic pain. In addition, the GDG decided that the HTA report included thorough data on the cost effectiveness of treatment pathways (sequences) for the subpopulations with PHN and PDN. On this basis, the economic evidence review for this guideline excluded papers on people with PHN or PDN.

Number of Source Documents

A total of 23,207 studies were retrieved by the systematic searches (antidepressants = 2,781, anti-epileptics = 4,757, opioid analgesics = 9,612, topical capsaicin and topical lidocaine = 6,057). From the 23,207 studies, 90 randomised placebo-controlled trials, 10 head-to-head comparative trials and four combination therapy trials were included, based on the inclusion and exclusion criteria suggested by the GDG through two short questionnaires. The searches did not identify any placebo-controlled studies that met the inclusion and exclusion criteria for 15 of the pharmacological treatments (see Table 4 in the full version of the current guideline). The 104 included studies are summarised in Table 5 of the full version of the guideline.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Not Given)
Rating Scheme for the Strength of the Evidence

Not available

Methods Used to Analyze the Evidence
Meta-Analysis
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Analysis and Synthesis

The primary outcomes for meta-analysis, based on the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations, were: at least 30% pain reduction; at least 50% pain reduction; patient-reported global improvement; and adverse effects. Specific adverse effects for each drug class were selected by the Guideline Development Group (GDG) (see Appendix 9.3 in the full version of the guideline), based on the expert knowledge and experience of GDG members (including that of patient and carer members). A fixed-effects model meta-analysis by subclass of the pharmacological treatment (for example, antidepressants: tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs], serotonin–norepinephrine reuptake inhibitors [SNRIs]) or by individual drug of the pharmacological treatment (for example, anti-epileptics: pregabalin, gabapentin, oxcarbazepine, lamotrigine, carbamazepine, phenytoin, sodium valproate, topiramate) was carried out on the primary outcomes. Where there was significant heterogeneity, a random-effects model was adopted for the meta-analysis (for further information on methodology, see the review protocol in Appendix 9.2 in the full version of the guideline). All results from the meta-analyses (relative risk or risk ratio [RR], absolute risk reduction [ARR], absolute risk increase [ARI], number-needed-to-treat to benefit [NNTB] and number-needed-to-treat to harm [NNTH]) are presented in GRADE profiles (for GRADE methodology, see Appendix 9.9 in the full version of the guideline) and subsequent evidence statements. No studies were excluded on the basis of outcomes.

For the completeness of the evidence base, included studies that did not report the primary outcomes recommended by the IMMPACT recommendations (at least 30% pain reduction; at least 50% pain reduction; patient-reported global improvement; adverse effects) were summarised in evidence tables (see Appendix 9.9 in the full version of the guideline). Pain outcomes (other than the primary outcomes) reported in these studies are presented in GRADE profiles and evidence statements as 'other reported pain outcomes'. The 'other reported pain outcomes' included mean pain relief score, mean pain intensity score, mean change in pain relief score from baseline, mean change in pain intensity score from baseline and mean change in daily pain score. Only evidence on the primary outcomes recommended by the IMMPACT recommendations (at least 30% pain reduction; at least 50% pain reduction; patient-reported global improvement; adverse effects) was used to generate recommendations. However, where evidence on the primary outcomes for particular pharmacological treatments was scarce or limited, evidence from 'other reported pain outcomes' was used to assist and generate discussion among the GDG to reach consensus, but not as the sole basis for making recommendations. For included studies that did not report either primary outcomes or 'other reported pain outcomes', study characteristics were summarised in the evidence tables for information (see the evidence tables in Appendix 9.9 in the full version of the guideline for full information on each included study).

Health Economics Methods

No health economic modelling was undertaken for this guideline because there was a relevant health technology assessment (HTA) monograph in development to which the GDG had been given access (The clinical and cost-effectiveness of different treatment pathways for neuropathic pain [NP]. National Institute for Health Research [NIHR] HTA programme, ref. 05/30/03. In press. Project abstract available from www.hta.ac.uk/1527 External Web Site Policy). The GDG reviewed, appraised and summarised the HTA report, and the results of the economic analyses from the HTA report informed this guideline as appropriate.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Forming the Clinical Summaries and Recommendations

Once the GRADE profile tables relating to a particular clinical question were completed, summary tables incorporating important information from the GRADE profiles were developed (these tables are presented in the evidence chapters of the full version of the guideline).

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

No health economic modelling was undertaken for this guideline because there was a relevant health technology assessment (HTA) monograph in development to which the guideline development group (GDG) had been given access. The GDG reviewed, appraised, and summarised the HTA report, and the results of the economic analyses from the HTA report informed this guideline as appropriate.

The HTA report focused on two neuropathic pain populations: people with post-herpetic neuralgia (PHN) and people with painful diabetic neuropathy (PDN). A systematic review of the economic evidence was also performed as part of the evidence review for this guideline. A systematic search found a total of 2,273 papers. Full details on the search strategy can be found in Appendix 9.7 of the full version of the guideline.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (The full guideline guideline and Quick Reference Guide) were consulted with stakeholders and comments were considered by the Guideline Development Group (GDG).
  2. The final consultation draft of the full guideline and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Key Principles of Care

Consider referring the person to a specialist pain service1 and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, if:

  • They have severe pain or
  • Their pain significantly limits their daily activities and participation2 or
  • Their underlying health condition has deteriorated

Continue existing treatments for people whose neuropathic pain is already effectively managed.3

Address the person's concerns and expectations when agreeing which treatments to use by discussing:

  • The benefits and possible adverse effects of each pharmacological treatment
  • Why a particular pharmacological treatment is being offered
  • Coping strategies for pain and for possible adverse effects of treatment
  • That non-pharmacological treatments are also available in non-specialist settings and/or through referral to specialist services (for example, surgical treatments and psychological therapies)

When selecting pharmacological treatments, take into account:

Explain both the importance of dosage titration and the titration process, providing written information if possible.

When withdrawing or switching treatment, taper the withdrawal regimen to take account of dosage and any discontinuation symptoms.

When introducing a new treatment, consider overlap with the old treatments to avoid deterioration in pain control.

After starting or changing a treatment, perform an early clinical review of dosage titration, tolerability and adverse effects to assess the suitability of the chosen treatment.

Perform regular clinical reviews to assess and monitor the effectiveness of the chosen treatment. Each review should include assessment of:

First-line Treatment

Offer oral amitriptyline* or pregabalin as first-line treatment (but see recommendation below for people with painful diabetic neuropathy)

  • For amitriptyline*: start at 10 mg per day, with gradual upward titration to an effective dose or the person's maximum tolerated dose of no higher than 75 mg per day (higher doses could be considered in consultation with a specialist pain service).
  • For pregabalin: start at 150 mg per day (divided into two doses; a lower starting dose may be appropriate for some people), with upward titration to an effective dose or the person's maximum tolerated dose of no higher than 600 mg per day (divided into two doses).

For people with painful diabetic neuropathy, offer oral duloxetine as first-line treatment. If duloxetine is contraindicated, offer oral amitriptyline*.

  • For duloxetine: start at 60 mg per day (a lower starting dose may be appropriate for some people), with upward titration to an effective dose or the person's maximum tolerated dose of no higher than 120 mg per day.
  • For amitriptyline*, see recommendation above.

Based on both the early and regular clinical reviews:

  • If there is satisfactory improvement, continue the treatment; consider gradually reducing the dose over time if improvement is sustained.
  • If amitriptyline* as first-line treatment results in satisfactory pain reduction but the person cannot tolerate the adverse effects, consider oral imipramine* or nortriptyline* as an alternative.

*In these recommendations, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (March 2010). Informed consent should be obtained and documented.

Second-line Treatment

If satisfactory pain reduction is not achieved with first-line treatment at the maximum tolerated dose, offer treatment with another drug instead of or in combination with the original drug, after informed discussion with the person.

  • If first-line treatment was with amitriptyline* (or imipramine* or nortriptyline*), switch to or combine with oral pregabalin.
  • If first-line treatment was with pregabalin, switch to or combine with oral amitriptyline* (or imipramine* or nortriptyline* as an alternative if amitriptyline* is effective but the person cannot tolerate the adverse effects.
  • For people with painful diabetic neuropathy:
    • If first-line treatment was with duloxetine, switch to amitriptyline or pregabalin, or combine with pregabalin.
    • If first-line treatment was with amitriptyline*, switch to or combine with pregabalin.

    See "First-line Treatment" section above for dosage and titration.

*In these recommendations, drug names are marked with an asterisk if they do not have UK marketing authorisation for the indication in question at the time of publication (March 2010). Informed consent should be obtained and documented.

Third-line Treatment

If satisfactory pain reduction is not achieved with second-line treatment:

  • Refer the person to a specialist pain service and/or a condition-specific service1 and
  • While waiting for referral:
    • Consider oral tramadol as third-line treatment instead of or in combination4 with the second-line treatment.
    • Consider topical lidocaine5 for treatment of localised pain for people who are unable to take oral medication because of medical conditions and/or disability.

For tramadol as monotherapy, start at 50 to 100 mg not more often than every 4 hours, with upward titration if required to an effective dose or the person's maximum tolerated dose of no higher than 400 mg per day. If tramadol is used as combination therapy, more conservative titration may be required.

Other Treatments

Do not start treatment with opioids (such as morphine or oxycodone) other than tramadol without an assessment by a specialist pain service or a condition-specific service1.

Pharmacological treatments other than those recommended in this guideline that are started by a specialist pain service or a condition-specific service1 may continue to be prescribed in non-specialist settings, with a multidisciplinary care plan, local shared care agreements and careful management of adverse effects.

1A condition-specific service is a specialist service that provides treatment for the underlying health condition that is causing neuropathic pain. Examples include neurology, diabetology and oncology services.

2The World Health Organization ICF (International Classification of Functioning, Disability and Health) (2001) defines participation as 'A person's involvement in a life situation.' It includes the following domains: learning and applying knowledge, general tasks and demands, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas, community, and social and civil life.

3Note that there is currently no good-quality evidence on which to base specific recommendations for treating trigeminal neuralgia. The GDG expected that current routine practice will continue until new evidence is available (see also section 3.1 in the full version of the guideline).

4The combination of tramadol with amitriptyline, nortriptyline, imipramine or duloxetine is associated with only a low risk of serotonin syndrome (the features of which include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus).

5Topical lidocaine is licensed for post-herpetic neuralgia, but not for other neuropathic pain conditions.

Clinical Algorithm(s)

An algorithm of the neuropathic pain care pathway is available in the full version of the guideline and in the quick reference guide (see "Availability of Companion Documents").

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate management of neuropathic pain
  • Pain reduction
  • Improved quality of life
Potential Harms
  • Adverse effects of pharmacological treatments
  • Withdrawal from therapy

Contraindications

Contraindications

Safety considerations and contraindications are detailed in each drug's summary of product characteristics (SPC).

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
  • For all drugs, recommendations are based on evidence of clinical and cost effectiveness and reflect whether their use for the management of neuropathic pain is a good use of National Health Service (NHS) resources. This guideline should be used in conjunction with clinical judgement and decision-making appropriate for the individual patient.
  • The guideline will assume that prescribers will use a drug's summary of product characteristics (SPC) and the British National Formulary (BNF) to inform decisions made with individual patients (this includes obtaining information on special warnings, precautions for use, contraindications and adverse effects of pharmacological treatments). However, the Guideline Development Group (GDG) agreed that having clear statements on drug dosage and titration in the actual recommendations is crucial for treatment in non-specialist settings, to emphasise the importance of titration to achieve maximum benefit.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Centre for Clinical Practice. Neuropathic pain. The pharmacological management of neuropathic pain in adults in non-specialist settings. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 155 p. (Clinical guideline; no. 96).  [122 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Mar
Guideline Developer(s)
National Institute for Health and Care Excellence (NICE) - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members: Peter Barry (Chair), Consultant in Paediatric Intensive Care, University Hospitals of Leicester NHS Trust and Honorary Senior Lecturer, Department of Child Health, University of Leicester; Tracey Cole, Patient and carer representative; Paula Crawford, Lead Clinical Pharmacist, Musgrave Park Hospital, Belfast; Peter Crome, Professor of Geriatric Medicine, Keele University and Consultant Geriatrician, North Staffordshire Combined Healthcare NHS Trust; Niru Goenka; Consultant Physician, Countess of Chester NHS Foundation Trust; Clair Haslam (resigned from GDG after meeting 3), Nurse Consultant, Pain Management and Neuromodulation, The Walton Centre, Liverpool; John Lee, Consultant in Pain Medicine, University College London (UCL) Hospitals and Honorary Senior Lecturer, UCL; Vera Neumann, Consultant and Honorary Senior Lecturer in Rehabilitation Medicine, Leeds Teaching Hospitals NHS Trust and University of Leeds; David Rowbotham, Professor of Anaesthesia and Pain Management, Department of Health Sciences, Leicester Medical School, University of Leicester; Blair H. Smith, Professor of Primary Care Medicine, University of Aberdeen, and GP, Peterhead Medical Practice; Heather Wallace, Patient and carer representative

Co-opted Member: The following person was not a full member of the Guideline Development Group but was co-opted onto the group as an expert adviser: Soloman Tesfaye, Consultant Physician/Endocrinologist, Royal Hallamshire Hospital, Sheffield and Honorary Professor of Diabetic Medicine, University of Sheffield

Short Clinical Guidelines Technical Team Members: Emma Banks, Guidelines Coordinator; Nicole Elliott, Guidelines Commissioning Manager (until September 2009); Sarah Glover, Information Specialist, Michael Heath, Programme Manager; Victoria Kelly, Project Manager; Fergus Macbeth, Director, Centre for Clinical Practice; Stefanie Reken (née Kuntze), Technical Analyst (Health Economics); Beth Shaw, Technical Adviser; Toni Tan, Technical Analyst, Judith Thornton, Technical Analyst; Claire Turner, Guidelines Commissioning Manager (from September 2009)

Financial Disclosures/Conflicts of Interest

A full list of all declarations of interest made by the Guideline Development Group (GDG) is available on the National Institute for Health and Clinical Excellence (NICE) Web site (www.nice.org.uk External Web Site Policy).

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available from the National Institute for Health and Care Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 6 p. (Clinical guideline; no. 96). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Neuropathic pain. Audit support. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 12 p. (Clinical guideline; no. 96). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Neuropathic pain. Costing statement. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 6 p. (Clinical guideline; no. 96). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Neuropathic pain. Slide set. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 21 p. (Clinical guideline; no. 96). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Neuropathic pain. Baseline assessment tool. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. (Clinical guideline; no. 96). Electronic copies: Available from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

  • Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings. Understanding NICE guidance. Information for people who use NHS services. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 12 p. (Clinical guideline; no. 96). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on January 17, 2011.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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