anti-neuropathic med for patient with cirrhosis

[ctts]

Does anyone have a anti-neuropathic pain med suggestion for patients who have liver disease? Specifically, I have a patient with Hep C,who at one point was told he has cirrhosis and later told he doesn't, but has what seems to be a very painful peripheral polyneuropathy. The problem is he has already tried gabapentin, which he could not tolerate due to cognitive side effects and no relief. For this reason, he also does not want to try Lyrica. I looked up Cymbalta and hepatic impairment is listed under its contraindications/caution. Nortriptyline, topiramate, Zonegran, states caution if hepatic impairment. I am running out of ideas...

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[clubdeac]

Does anyone have a anti-neuropathic pain med suggestion for patients who have liver disease? Specifically, I have a patient with Hep C,who at one point was told he has cirrhosis and later told he doesn't, but has what seems to be a very painful peripheral polyneuropathy. The problem is he has already tried gabapentin, which he could not tolerate due to cognitive side effects and no relief. For this reason, he also does not want to try Lyrica. I looked up Cymbalta and hepatic impairment is listed under its contraindications/caution. Nortriptyline, topiramate, Zonegran, states caution if hepatic impairment. I am running out of ideas...

keppra

 

[Ducttape]

lidoderm patch?

topical compounding cream containing bupiv and clonidine?

alpha lipoic acid?

zostrix cream?

 

[melancholy]

i love keppra lol. coudl also consider oxcarbazepine.

 

[bedrock]

i love keppra lol. coudl also consider oxcarbazepine.

Ditto on both. I'd start with a compounded cream.

 

[Dr. Ice]

Ditto on both. I'd start with a compounded cream.

which wont be covered by his insurance

 

[cordycep]

Does anyone have a anti-neuropathic pain med suggestion for patients who have liver disease? Specifically, I have a patient with Hep C,who at one point was told he has cirrhosis and later told he doesn't, but has what seems to be a very painful peripheral polyneuropathy. The problem is he has already tried gabapentin, which he could not tolerate due to cognitive side effects and no relief. For this reason, he also does not want to try Lyrica. I looked up Cymbalta and hepatic impairment is listed under its contraindications/caution. Nortriptyline, topiramate, Zonegran, states caution if hepatic impairment. I am running out of ideas...

Herbs work best for cirrhosis, Acupuncture would be great for neuropathic pain quickly..beside NO SIDE EFFECT -be open minded. Beside most meds would just make his/her cirrhosis worst and not treat the problem.

 

[BobBarker]

Herbs like cannabis??

 

[mille125]

which wont be covered by his insurance

Compounded cream (ketamine clonidine lidocaine ketoprofen). If insurance doesn't cover it he can probably get a private pay price for under $100. Keppra and trileptal also also good suggestions.


Stim trial?

 

[lobelsteve]

Compounded cream (ketamine clonidine lidocaine ketoprofen). If insurance doesn't cover it he can probably get a private pay price for under $100. Keppra and trileptal also also good suggestions.


Stim trial?

Never met anyone with the balls enough to claim they actually get results for PN from SCS to say so. I've got a drawer of batteries from other providers that says it doe not work.

Most patients report 2-3 months of relief then it quits working. When used properly, SCS is a procedure of last resort. When used liberally it is a boat payment.

 

[mille125]

Never met anyone with the balls enough to claim they actually get results for PN from SCS to say so. I've got a drawer of batteries from other providers that says it doe not work.

Most patients report 2-3 months of relief then it quits working. When used properly, SCS is a procedure of last resort. When used liberally it is a boat payment.

Agreed......... but you would have to agree that this scenario is a last resort...............

 

[Ducttape]

Herbs work best for cirrhosis, Acupuncture would be great for neuropathic pain quickly..beside NO SIDE EFFECT -be open minded. Beside most meds would just make his/her cirrhosis worst and not treat the problem.

pubmed lists 1 article, published in 2009, that discusses acupuncture in compensated cirrhosis in a poorly designed and not controlled study.

also, herbs can be potentially fatal for someone with cirrhosis.

heres hoping no patient with end stage liver disease with concomitant lack of clotting factors gets acupuncture, or is on herbs such as ginseng, ginkoba, or even ginger..

 

[mille125]

pubmed lists 1 article, published in 2009, that discusses acupuncture in compensated cirrhosis in a poorly designed and not controlled study.

also, herbs can be potentially fatal for someone with cirrhosis.

heres hoping no patient with end stage liver disease with concomitant lack of clotting factors gets acupuncture, or is on herbs such as ginseng, ginkoba, or even ginger..

Thanks for bringing this up. There are so many patients and docs who underestimate the anticoagulant properties of "herbs". An argument can be made that a cirrhotic (ie this patient) would be the absolute worse patient to entertain these therapies. I am not against fish oil, flax seed oil, ginseng, etc but for some reason there is a feeling especially among patients that these meds are side effect free.

 

[bedrock]

Never met anyone with the balls enough to claim they actually get results for PN from SCS to say so. I've got a drawer of batteries from other providers that says it doe not work.

Most patients report 2-3 months of relief then it quits working. When used properly, SCS is a procedure of last resort. When used liberally it is a boat payment.

I must have rather large cojones because yes I have have gotten good results treating PN with SCS. I actually brought this up a year ago on SDN in the same circumstance, after steve similarly broadly stated that SCS never ever works for PN.

SCS does work in PN (For rare carefully selected patients) I average one stim implant per year for this, so yeah, I'm very careful who I use it on, in comparison to the boat-funding pain docs in Steve's neck of the woods.
Criteria is simple. The primary complaint must be moderate-severe burning pain, unrelieved by at least 4 oral + 1 topical neuropathic med.
The vast majority of usual PN patients have numbness, paresthesias, maybe some uncomfortable numbness. Most patients with painful PN can obtain reasonable pain control with neuropathic meds. SCS is clearly not for these patients.

For someone with moderate-severe burning neuropathic PN pain unrelieved by any other medical treatment, are you just going to tell them that they are doomed to live with the pain forever??????

Just did my one case of this year a few weeks ago. Normal guy with burning foot pain so bad he can't wear shoes....ever. Failed 5 meds and a topical. 80% relief after his trial with leads across T12-L1. The guy literally hugged me he was so happy.

So I wouldn't be quite so dogmatic about this, Steve. There are exceptions to every rule. I'm sure you're right about SCS for PN 98% of the time. But don't forget the 2%.

 

[lobelsteve]

I must have rather large cojones because yes I have have gotten good results treating PN with SCS. I actually brought this up a year ago on SDN in the same circumstance, after steve similarly broadly stated that SCS never ever works for PN.

SCS does work in PN (For rare carefully selected patients) I average one stim implant per year for this, so yeah, I'm very careful who I use it on, in comparison to the boat-funding pain docs in Steve's neck of the woods.
Criteria is simple. The primary complaint must be moderate-severe burning pain, unrelieved by at least 4 oral + 1 topical neuropathic med.
The vast majority of usual PN patients have numbness, paresthesias, maybe some uncomfortable numbness. Most patients with painful PN can obtain reasonable pain control with neuropathic meds. SCS is clearly not for these patients.

For someone with moderate-severe burning neuropathic PN pain unrelieved by any other medical treatment, are you just going to tell them that they are doomed to live with the pain forever??????

Just did my one case of this year a few weeks ago. Normal guy with burning foot pain so bad he can't wear shoes....ever. Failed 5 meds and a topical. 80% relief after his trial with leads across T12-L1. The guy literally hugged me he was so happy.

So I wouldn't be quite so dogmatic about this, Steve. There are exceptions to every rule. I'm sure you're right about SCS for PN 98% of the time. But don't forget the 2%.

What about the cost of the other 98%?

Every PN patient fails at least 4 meds. The data suggests 70% success in PN for SCS. n=17. Data directly from St. Jude. And not any more believable than your yearly n of 1.
And I used to teach SCS for St. Jude. And have you read my chapter in Slipman?

But it's just me.

 

[mille125]

What about the cost of the other 98%?

Every PN patient fails at least 4 meds. The data suggests 70% success in PN for SCS. n=17. Data directly from St. Jude. And not any more believable than your yearly n of 1.
And I used to teach SCS for St. Jude. And have you read my chapter in Slipman?

But it's just me.

It is interesting that you discredit data from st jude but believe everything that the lyrica reps tell you. You need to have a healthy skepticism of both.

 

[lobelsteve]

It is interesting that you discredit data from st jude but believe everything that the lyrica reps tell you. You need to have a healthy skepticism of both.

What are you talking about RE: Lyrica rep?

Are you doing a lot of SCS for PN or something stupid like that?

Did I hit a nerve? The data from St Jude is based on 17 patients. It discredits itself and as a guy who used to teach for them it was tough selling it to other docs.

I'm skeptical of everything and everyone, especially a subjective phenomenon that cannot be proven by any means but always leads to expensive care.

 

[mille125]

What are you talking about RE: Lyrica rep?

Are you doing a lot of SCS for PN or something stupid like that?

Did I hit a nerve? The data from St Jude is based on 17 patients. It discredits itself and as a guy who used to teach for them it was tough selling it to other docs.

I'm skeptical of everything and everyone, especially a subjective phenomenon that cannot be proven by any means but always leads to expensive care.

You did not hit a nerve. I have done one stim for PN in my career (actually it did work longterm).


The lyrica comment is referring to a rant of yours several years ago on its superiority to gabapentin and everything else under the sun. It was obvious that the reps got to you or they were paying you. That is why I was amused by your st jude comment.......However, I am over it now...

 

[lobelsteve]

You did not hit a nerve. I have done one stim for PN in my career (actually it did work longterm).


The lyrica comment is referring to a rant of yours several years ago on its superiority to gabapentin and everything else under the sun. It was obvious that the reps got to you or they were paying you. That is why I was amused by your st jude comment.......However, I am over it now...

Rant was anti gabapentin. I still hate it and it's 1-2 month titration to see if it will work. Never paid by Pfizer.

 

[mille125]

Rant was anti gabapentin. I still hate it and it's 1-2 month titration to see if it will work. Never paid by Pfizer.

You don't have to like it but lyrica is not superior. It just costs more.

 

[lobelsteve]

You don't have to like it but lyrica is not superior. It just costs more.

But I can titrate it over 1 week to possibly effective levels and with samples and a seven day start card it's free for my patients.

 

[mille125]

But I can titrate it over 1 week to possibly effective levels and with samples and a seven day start card it's free for my patients.

Yes, but for how long....Sounds a lot like the "teaser" rate that a lot of companies give...........

 

[bustbones26]

Yes, but for how long....Sounds a lot like the "teaser" rate that a lot of companies give...........

A happy medium to consider would be an extended formulation of Gabapetin such as Gralise. More expensive the Gabapentin, but MUCH CHEAPER than Lyrica!! I use Gralise in those that cannot tolerate Gabapentin and they do well, that is less side effects.

As for costs, the drug reps have handed me several starter packs for Gralise, so that may be an option.

The data on Lamotrigine suggests that it is not as useful as other anti-epileptics for the treatment of neuropathic pain, but every so often I do have a patient that responds to it, the problem is slow titration due to fear of Stevens Johnsons. Even though that is the fear, the titration is faster than Gabapentin in most cases.