Chemotherapy induced peripheral neuropathy

[oneforfighting]

88yo with h/o chemotherapy induced neuropathy in BLE. Tried gabapentin, duloxtine, lyrica, topamax, ALA, topical lido/voltaren/menthol/capsaicin, TENS. Pt not interested in SCS, worried about sedation. Lives alone and also given age, I've tried to hold off on TCAs...but I may need to go that route as pain is worsening. What else can I offer? LESI??

---

Members don't see this ad.

 

[jwalker12]

Nucynta?

 

[pastafan]

Oxcarbazepine titration may work.

 

[bedrock]

Agree with nucynta

 

[lobelsteve]

keppra. Then stim. If declines, then nothing, if fails, then nothing. Send to University, failed enough to know we cannot successfully treat everyone.

 

[oneforfighting]

Thanks all.

 

[kstarm]

low dose TCA is reasonable but I have the same concerns about side effects. I would try butrans probably before nucynta despite nucynta having a better mechanism due to side effect profile and ease of dosing. Could try topical ketamine too.

 

[Ferrismonk]

I'd also consider B vitamins supplementation.

 

[camkiss]

Agree with @Ferrismonk- I’ve had a lot of success with benfotiamine and alpha lipoic acid combo, especially with chemotherapy induced neuropathy.

 

[Ducttape]

desipramine may be more tolerated than nortrip and amitrip. twice daily dosing.

CBD oil, topically most likely. in states where legal or medical, she could try that.

nucynta prob not available as i dont believe Medicare covers it any longer, so horribly expensive. i have had to transition the few people i prescribe that to to a different agent.

compression socks, 15-20 mmHg wear first thing in morning.

 

[oneforfighting]

Agree with @Ferrismonk- I’ve had a lot of success with benfotiamine and alpha lipoic acid combo, especially with chemotherapy induced neuropathy.

On ALA already. What’s the dosing on benfotiamine? Just B1 right?

 

[GlowInTheDark]

I had something similar, Butrans has helped significantly.

 

[oneforfighting]

low dose TCA is reasonable but I have the same concerns about side effects. I would try butrans probably before nucynta despite nucynta having a better mechanism due to side effect profile and ease of dosing. Could try topical ketamine too.

Is Topical ketamine compound pharmacy only? Dosing/freq?
Butrans dosing for opioid naive? Buccal or transdermal for elderly?

Don’t have experience with either.

 

[oneforfighting]

I had something similar, Butrans has helped significantly.

Butrans dosing for opioid naive? Buccal or transdermal for elderly?

 

[GlowInTheDark]

Butrans dosing for opioid naive? Buccal or transdermal for elderly?

I’ve only recently started using it, haven’t used Buccal for elderly. 5mcg/hr is lowest dose and recommended for the opioid naive. I recommend reading the physician info on their websites for dosing/application/etc. I insist my patients “speak to the pharmacist” when they pick it up so they know how to use it.

 

[Espn123]

I’ve had trouble getting scs approved for it

 

[cowboydoc]

Is Topical ketamine compound pharmacy only? Dosing/freq?
Butrans dosing for opioid naive? Buccal or transdermal for elderly?

Don’t have experience with either.

It’s controlled, so yes. Q4h prn
5mcg/hr transdermal (or whatever insurance will cover). May titrate in a month if needed.

 

[Orin]

Consider Qutenza (High-dose 8% capsaicin patch in treatment of chemotherapy-induced peripheral neuropathy: single-center experience)

Trial Mexiletine or another sodium channel blocker. Some places have had amazing results with lidocaine infusions for CIPN.

Do an LSB. If it helps, consider DRG/SCS or IT therapy.

Consider PNS of the sciatic.

 

[drg123]

Bilateral SPR PNS? I find people who are against an SCS surprisingly amenable to PNS, especially if its a temporary perc like SPR.

 

[oneforfighting]

5mcg/hr transdermal (or whatever insurance will cover). May titrate in a month if needed.

Screen qtc before initiation?
And do you have to do regular urine drug screens? I don’t normally prescribe narcotics so trying to keep it simple.

 

[camkiss]

On ALA already. What’s the dosing on benfotiamine? Just B1 right?

It’s fat soluble B1. Recommend 200-600mg daily.

 

[cowboydoc]

Screen qtc before initiation?
And do you have to do regular urine drug screens? I don’t normally prescribe narcotics so trying to keep it simple.

No ekg routinely. Annual uds if low risk (ORT).

 

[soccrwz]

Agree with @Ferrismonk- I’ve had a lot of success with benfotiamine and alpha lipoic acid combo, especially with chemotherapy induced neuropathy.

Can you explain why you use benfotiamine? Wondering if I should add this over b complex

 

[MitchLevi]

Can someone briefly summarize what yall do with Nucynta? I have one patient on it and I've basically done nothing but just Rx it to her. Come to think of it, she hasn't been back in awhile (like 6m or so).

Is this truly a better option than Norco 5-7.5 BID PRN for a geriatric patient with a blown up spine?

 

[camkiss]

Can you explain why you use benfotiamine? Wondering if I should add this over b complex

Because it is lipid soluble, it is more bioavailable as well as able to penetrate the nerve better than regular B1. I have patients purchase from Amazon along with the ALA.

 

[Ducttape]

Can someone briefly summarize what yall do with Nucynta? I have one patient on it and I've basically done nothing but just Rx it to her. Come to think of it, she hasn't been back in awhile (like 6m or so).

Is this truly a better option than Norco 5-7.5 BID PRN for a geriatric patient with a blown up spine?

Positives:
ER dosing makes it easy to give and take
IMO, less sedation
Less constipation than norco
One can conceptualize that it may have more neuropathic painrelief

Less street value. Doesn't give the high that addicts want.

Negatives:
Potential interaction with SSRIs
May not be covered by insurance
Have to request special urine test
$$$

Did I mention $$$?

For ER version, I start 50 mg twice daily. For the IR, 50 mg three times a day, can increase to max 400 mg, but I have not had to.

 

[Ferrismonk]

Positives:
ER dosing makes it easy to give and take
IMO, less sedation
Less constipation than norco
One can conceptualize that it may have more neuropathic painrelief

Less street value. Doesn't give the high that addicts want.

Negatives:
Potential interaction with SSRIs
May not be covered by insurance
Have to request special urine test
$$$

Did I mention $$$?

For ER version, I start 50 mg twice daily. For the IR, 50 mg three times a day, can increase to max 400 mg, but I have not had to.

One more negative is that the PDMP states the MMED is stupid high.

 

[MitchLevi]

Positives:
ER dosing makes it easy to give and take
IMO, less sedation
Less constipation than norco
One can conceptualize that it may have more neuropathic painrelief

Less street value. Doesn't give the high that addicts want.

Negatives:
Potential interaction with SSRIs
May not be covered by insurance
Have to request special urine test
$$$

Did I mention $$$?

For ER version, I start 50 mg twice daily. For the IR, 50 mg three times a day, can increase to max 400 mg, but I have not had to.

Thanks.

Are there ancillary steps that need to be taken? EKG, etc?

 

[DODOCSS]

Thanks.

Are there ancillary steps that need to be taken? EKG, etc?

no

 

[MitchLevi]

I want to Rx more of it for certain ppl but it's like $300 per month for some ppl.

 

[BobBarker]

You should be seeing them more than every 6m. Schedule 2 opioid.

 

[drrosenrosen]

Price is a frustratingly common barrier to the meds I'd like to prescribe more of - Butrans, Belbuca, Nucynta. Maybe in addition to intentionally cutting the supply of hydrocodone in the US, the government could also look at negotiating prices and coverages on the meds they're paying for.

 

[MitchLevi]

You should be seeing them more than every 6m. Schedule 2 opioid.

I think this lady may just have left the practice. I do Q3M opiates.

 

[specepic]

LDN?

 

[MitchLevi]

LDN?

I'd love to hear some success stories for LDN because I've only seen it fail (fellowship).

 

[kstarm]

I'd love to hear some success stories for LDN because I've only seen it fail (fellowship).

I have maybe 10-15 patients with fibro et al, that like it and think it helps and continue on it. Maybe 3 of those were "homeruns" where it really changed their pain. I haven't really used it for peripheral neuropathy if that is the success you were wondering about, but pretty low risk to consider.

 

[Forwho]

It’s fat soluble B1. Recommend 200-600mg daily.

what's the dosing on ALA? 600? 1200?

 

[MitchLevi]

what's the dosing on ALA? 600? 1200?

300mg TID for my pts

 

[specepic]

I'd love to hear some success stories for LDN because I've only seen it fail (fellowship).

Very good results for FMPS. Would admitedly be a hail mary in this case but some type of central pain disorder could be a factor here given the lack of response of so many treatments. It is a great placebo (half kidding)

 

[camkiss]

what's the dosing on ALA? 600? 1200?

600-900mg daily

 

[painfree23]

I think this lady may just have left the practice. I do Q3M opiates.

All opiates are q3 months? How do u do refills in between?

 

[MitchLevi]

All opiates are q3 months? How do u do refills in between?

Prob around 90% are Q3M.

Vast majority of my opiate pts are geriatric with terrible spines.

I send over 3 Rx to pharmacy.

 

[Ducttape]

All opiates are q3 months? How do u do refills in between?

the "guidelines" are "no greater than 3 months".

you cannot send in a script for Schedule II medications with refills

some states may allow "do not fill until" prescriptions.

you can write for "Code D" prescription and include >30 days prescription. it should be reserved for unusual situations. and the prescription has to say "Code D x days" on it.

 

[redchyvak]

keppra. Then stim. If declines, then nothing, if fails, then nothing. Send to University, failed enough to know we cannot successfully treat everyone.

Just curious how you’d get something like this approved? I had one patient I was considering SCS on and was going to use cancer-related pain, but was told because it was from chemotherapy and not directly due to cancer it wouldn’t qualify.

 

[lobelsteve]

Just curious how you’d get something like this approved? I had one patient I was considering SCS on and was going to use cancer-related pain, but was told because it was from chemotherapy and not directly due to cancer it wouldn’t qualify.

Document failed therapies and put in chronic intractable pain of the trunk/limb with PN code.

 

[clubdeac]

anyone combine LDN and alpha stim for their fibro patients? would be interesting to see a study with these 4 arms: 1) LDN 2) alpha stim 3) LDN + alpha stim 4) control group

Once I decide to slow down and cut back on my interventional stuff I think I'll start a fibro clinic. My treatments options will include Lyrica, Cymbalta, TCAs, LDN, B complex, Vit D, ketamine, green light therapy, HIIT, aquatic therapy, alpha stim, autogenic training and transcendental mediation. you could probably fill up a clinic cycling through these options over and over all day long. May be a pretty easy gig actually

 

[drrosenrosen]

anyone combine LDN and alpha stim for their fibro patients? would be interesting to see a study with these 4 arms: 1) LDN 2) alpha stim 3) LDN + alpha stim 4) control group

Once I decide to slow down and cut back on my interventional stuff I think I'll start a fibro clinic. My treatments options will include Lyrica, Cymbalta, TCAs, LDN, B complex, Vit D, ketamine, green light therapy, HIIT, aquatic therapy, alpha stim, autogenic training and transcendental mediation. you could probably fill up a clinic cycling through these options over and over all day long. May be a pretty easy gig actually

How do you bill alpha stim? Cash only?

 

[clubdeac]

How do you bill alpha stim? Cash only?

that's a very good question. I had a rep come by a few years ago but I rarely prescribed it so he left. I think I could only get it covered for my VA patients and Tricare