Why ▼ pregabalin?

When it comes to health economic evaluations, much has to be taken on trust. Data and assumptions for therapeutic interventions are fed into an evaluation model and a series of answers emerge at the other end. If the data are sufficiently clear-cut and robust and the assumptions reasonable, the evaluation and the resulting recommendations may be both sound and useful. It is questionable whether this is the case with the recently published National Institute for Health and Clinical Excellence guideline on neuropathic pain.1

This guideline is based on an economic evaluation and recommends that clinicians should “offer oral amitriptyline or pregabalin as first-line treatment…”. The guideline specifically excludes gabapentin as a treatment option for neuropathic pain, based on indirect comparisons suggesting that, in relation to pregabalin, it offers less net benefit, is less cost-effective, and requires more complex dosing and titration.1 Of note, however, pregabalin is still a black triangle drug being intensively monitored, and this too should be considered in any comparison with the much longer established gabapentin.

And the guideline's promotion of pregabalin creates a dilemma for those who know from the published data that gabapentin remains an effective treatment option for neuropathic pain. Gabapentin is by far the cheaper of the two drugs (with 28 days' treatment at 1,200mg three times daily costing £14.57, compared with £64.40 for pregabalin 300mg twice daily [both maximum daily doses]); and therefore for the same level of investment, the NHS faces the choice of treating more patients with a cheaper but (on indirect evidence) slightly less effective drug, or fewer patients with a more expensive, seemingly more effective one. So can clinicians be sure that a wholesale switch away from using gabapentin is a justifiable and affordable investment option? At a time of belt-tightening in the NHS, this could be …