What do you guys prefer for neuropathic pharm treatment?

[Blitz2006]

I'm a Psych resident, hoping to go into pain.

Anyways, our program, if we have a patient with depression and neuropathic pain, we seem to always jump straight for Cymbalta.

Was interested what the literature/your anecdotal data suggests for neuropathic pain? Effexor? Elavil? Neurontin?

Is Cymbalta the best?

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[willabeast]

1. tricyclics best for burning. can cause arrythmias if long QT interval. need to taper up.
2. gabapentin best for shooting electrical. can lose short term memory. taper up.
3. cymbalta does not work as well as either of the above. but it does work sometimes.
4. sometimes, rarely, lyrica works when gabapentin does not
5. it is OK to combine #1 and #2 or #2 and #3.
6. depakote if you really want to exhaust everything. watch liver, platelets.
7. if patient is on anti-depressants for depression, and they are working, don't mess with them.

 

[101N]

8. Alpha Lipoic Acid (OTC)
9. If it's legal in your state, you could consider
Charlotte's Web: https://cbdoilreview.org/cw-botanicals-review/

 

[Blitz2006]

So effexor is not even on the radar.

Good to know

 

[Tapspatellas]

So effexor is not even on the radar.

Good to know

Effexor up titrated to at least 150 if cymbalta isn't covered and that was what I was wanting to prescribe. Isn't very helpful, like cymbalta, in my opinion.

 

[Blitz2006]

Effexor up titrated to at least 150 if cymbalta isn't covered and that was what I was wanting to prescribe. Isn't very helpful, like cymbalta, in my opinion.

Sounds good. Just cause I have patterns with depression and neuropathy, which is why I'm asking about effexor.

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[bedrock]

Sounds good. Just cause I have patterns with depression and neuropathy, which is why I'm asking about effexor.

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If you've got depression and neuropathic pain, I would start with cymbalta every time unless its not covered, in which case I would start with Effexor.

I agree with above that cymbalta doesn't work a lot of the time for neuropathic pain, but I have seen it work and help people with neuropathic pain, and in your position I would definitely start with it.

If someone has depression and neuropathic pain, that is most symptomatic at night/sleeping, and failed cymbalta, then go with daytime SSRI or SSNRI + QHS tricyclic or gabapentin, as QHS only dosing of those two is tolerated much better than daytime dosing.

Lyrica is useful for patient that had good pain relief with gabapentin, but couldn't tolerate the side effects of sedation, mental clouding, and memory loss which are less with lyrica, but still present if you write a high enough dose of Lyrica

Be aware that more patients report psych disturbances taking lyrica than with gabapentin, so with a mild-moderately complex psych patient I never start with lyrica, even if they have good insurance.

 

[Blitz2006]

Thanks. Helpful.

Among the TCAs do you guys prefer amitriptyline? Because of all the side effects we hardly use it for depression anymore, but shows good results it seems with pain.

So I want to start experimenting with TCAs in my patients that also have pain.

What's your target dose for amitriptyline? 300?

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[bedrock]

Thanks. Helpful.

Among the TCAs do you guys prefer amitriptyline? Because of all the side effects we hardly use it for depression anymore, but shows good results it seems with pain.

So I want to start experimenting with TCAs in my patients that also have pain.

What's your target dose for amitriptyline? 300?

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I prefer amitriptyline because it works on so many pain receptors, more than any other TCA. I only prescribe it QHS because it is so sedating. If you are doing BID dosing, then nortriptyline is a better option.

Important for you to know that effective TCA doses for pain are much less than for depression doses, which limits the side effects.

I'm generally shooting for 25-50mg QHS of amitriptyline, but for sensitive patients, I have them break the 25mg pill in half (so 12.5mg), and not sensitive or insomniac patients, I might increase to 75-100mg QHS. If only modest partial relief at 100mg, I will add another neuropathic agent.
I generally never write for more than 100mg of elavil, and I don't use TCAs in elderly, >65, frail patients , or those with known significant CAD or rhythm issues.

 

[Tapspatellas]

Thanks. Helpful.

Among the TCAs do you guys prefer amitriptyline? Because of all the side effects we hardly use it for depression anymore, but shows good results it seems with pain.

So I want to start experimenting with TCAs in my patients that also have pain.

What's your target dose for amitriptyline? 300?

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I like nortriptyline qhs personally, seems better tolerated. Same dosing as what bedrock said, work up to 50mg, sometimes 75. If it doesn't work, I'll change to another TCA, often amitriptyline, sometimes a 3rd before I give up.

I also will start with an SNRI if comorbid depression or anxiety, even though they constantly underwhelm me compared to anticonvulsants and TCA's. If you can get the depression a little better, the pain becomes easier to treat.

 

[Dr. Ice]

My go to is still gabapentin because quite frankly I just don't want to deal with the insurance denials of lyrica even though I find it to be a superior drug. All the constant prior auth is tiresome but then again I have **** demographic population with likely **** insurance plans within the insurance cloud of
their parent companies.

 

[Blitz2006]

I prefer amitriptyline because it works on so many pain receptors, more than any other TCA. I only prescribe it QHS because it is so sedating. If you are doing BID dosing, then nortriptyline is a better option.

Important for you to know that effective TCA doses for pain are much less than for depression doses, which limits the side effects.

I'm generally shooting for 25-50mg QHS of amitriptyline, but for sensitive patients, I have them break the 25mg pill in half (so 12.5mg), and not sensitive or insomniac patients, I might increase to 75-100mg QHS. If only modest partial relief at 100mg, I will add another neuropathic agent.
I generally never write for more than 100mg of elavil, and I don't use TCAs in elderly, >65, frail patients , or those with known significant CAD or rhythm issues.

Good to know, in psych we usually go up to 200-300 mg for amitriptyline for depression. But of course, as a resident, we are drilled that TCAs are dangers (side effect profile), so we almost never use it for MDD.

I'm glad that gabapentin works, again, from my anecdotal experience, psychiatrists think Neurontin is a junk drug that doesn't do anything.

 

[ampaphb]

If you are interested in pain psych, one of the best, most reasonable guys I know is Mordi Potash at Tulane. Happy to connect you if you like.

 

[Blitz2006]

If you are interested in pain psych, one of the best, most reasonable guys I know is Mordi Potash at Tulane. Happy to connect you if you like.

I'm very interested, will PM you.

 

[bedrock]

My go to is still gabapentin because quite frankly I just don't want to deal with the insurance denials of lyrica even though I find it to be a superior drug. All the constant prior auth is tiresome but then again I have **** demographic population with likely **** insurance plans within the insurance cloud of
their parent companies.

Agree that's super annoying and none of us have time to deal with insurance denials all the time.

One way I've found around this is two local family pharmacies that to encourage business will do prior auths for Lyrica, Nucynta, Butrans, Cymbalta, etc, so when writing those meds, I just do the script and the patient is given the pharmacy card and staff tells them the script must be filled at this pharmacy due to insurance, and that's it. Saves me lots of time, but my patients still get optimal care.

One caveat is the patient does need actual insurance for this to work. Fine with HMOs but not medicaid which isn't real insurance IMHO, which is another reason I don't see medicaid.

 

[ampaphb]

How do u do a prior auth without attributing the script to a specific patient?

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[bedrock]

How do u do a prior auth without attributing the script to a specific patient?

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I don't do the auth, that's the point. I print a script, and the pharmacy knows to get the prior auth. Often,The patient often can't pick up the medication that same day, but it generally gets approved and they appreciate the service of the family pharmacy, and some patients will them fill all their other scripts there.

 

[VA Hopeful Dr]

I don't do the auth, that's the point. I print a script, and the pharmacy knows to get the prior auth. Often,The patient often can't pick up the medication that same day, but it generally gets approved and they appreciate the service of the family pharmacy, and some patients will them fill all their other scripts there.

I've started recommending non-chain pharmacies for this exact reason as well

 

[DOctorJay]

I don't do the auth, that's the point. I print a script, and the pharmacy knows to get the prior auth. Often,The patient often can't pick up the medication that same day, but it generally gets approved and they appreciate the service of the family pharmacy, and some patients will them fill all their other scripts there.

is this common for non-chain pharmacies to do prior auths? I haven't heard that before.

 

[ampaphb]

So you write the script in anticipation of their visit for the same meds they got last time?

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[bedrock]

is this common for non-chain pharmacies to do prior auths? I haven't heard that before.

non chain pharmacies have to compete on services as they don't have the massive size to negotiate drug discounts like CVS and Walgreens.
If you ask family pharmacies in your area, I expect one is doing this. If not, they likely would if you ask them, in order to get more clients.

So you write the script in anticipation of their visit for the same meds they got last time?

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auth generally good for six months, I usually write a six month script anyway for lyrica, Cymbalta

For schedule 2-3 meds, like Nucynta, Butrans, the auth is generally good for six months. I write them a new script at each monthly or every other monthly visit.
If the dose changes, the pharmacy still handles the auth. Often the patient can still get the script the same day, as many auths are still good unless you change the number of pills the patient is getting per month.

 

[oreosandsake]

look up "Dworkin + neuropathic pain" or + "neupig"

recommendations from the IASP for tx neuropathic pain

 

[melancholy]

all above good information. there are multiple guidelines/recommendations from different organizations on options for neuropathic pain based on available research studies.

occasionally i will trial effexor first rather than cymbalta if patient complains of fatigue as well as sometimes it gives some people energy (although have to warn patient about temporary jitteriness and occaisonally have to give a short course of klonopin PRN in case). if effexor doesn't work or isn't tolerated, then cymbalta.

TCAs typically nortriptyline or elavil depending on tolerability. never get up to more than 30-50mg qhs usually, but occasionally a few up to 75mg at bedtime (at least for nortriptyline). occasionally will trial someone on desipramine or doxepin based upon side effect profile and other symptoms.

i see a fair amount of psychiatrists in our group that use gabapentin for insomnia, mood stabilization, etc as well as for neuropathic pain.

I occasionally will trial patients on other meds such as Topamax (swiss army knife of neuropathic meds if it is tolerated and works), keppra (if no mood issues or has liver impairment). once in awhile Trileptal. rarely Depakote. My IM colleague uses Tegretol every now and then as a last resort.

 

[SeniorWrangler]

There is a bimodal distribution with medication response -- patients tend to have either a good or a poor response to a given med. If you can keep them engaged, it's worth trials of a few different agents with different mechanisms. I agree with much of what Melancholy just said; I have had some really good responses to oxcarbazepine/carbamazepine in post-traumatic neuropathies.

 

[melancholy]

There is a bimodal distribution with medication response -- patients tend to have either a good or a poor response to a given med. If you can keep them engaged, it's worth trials of a few different agents with different mechanisms. I agree with much of what Melancholy just said; I have had some really good responses to oxcarbazepine/carbamazepine in post-traumatic neuropathies.

Post traumatic neuropathies such as plexopathies or peripheral mononeuropathies from trauma like GSW, stretch or fall, MVA?

 

[bedrock]

Agree with melancholy that topamax is Swiss Army knife of neuropathic pain. I almost always try topamax if someone has failed TCAs or gabapentin/lyrica.

Topamax seems to have a NNT of around 5-8, but the people who do respond to it, do extremely well. Plus, once I mention that people tend to lose weight on topamax, everyone is willing to try it.

 

[lobelsteve]

Agree with melancholy that topamax is Swiss Army knife of neuropathic pain. I almost always try topamax if someone has failed TCAs or gabapentin/lyrica.

Topamax seems to have a NNT of around 5-8, but the people who do respond to it, do extremely well. Plus, once I mention that people tend to lose weight on topamax, everyone is willing to try it.

Topamax is the only medication ever studied to show a benefit for radiculopathy.

 

[Taus]

Agree with melancholy that topamax is Swiss Army knife of neuropathic pain. I almost always try topamax if someone has failed TCAs or gabapentin/lyrica.

Topamax seems to have a NNT of around 5-8, but the people who do respond to it, do extremely well. Plus, once I mention that people tend to lose weight on topamax, everyone is willing to try it.

What's your typical dosing for pain w topamax?


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[Tapspatellas]

What's your typical dosing for pain w topamax?


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I start 25 qhs for a few days, then work up by 25mg per day to what they can tolerate. I don't go over 100 bid and stop at 75 bid often.

I don't reach for it as quick as the others, mainly due to the cognitive side effects. When I have a patient who wants to lose weight (most should) and is reluctant about taking any other antineuropathic, they are often open to a trial of topamax.

I will mention that if they are a kidney stone former, watch out. They will churn them out like crazy if you start them on it.

 

[lobelsteve]

25% of patients on topamax lose weight.

75% do not.

Most?

 

[bedrock]

I start 25 qhs for a few days, then work up by 25mg per day to what they can tolerate. I don't go over 100 bid and stop at 75 bid often.

I don't reach for it as quick as the others, mainly due to the cognitive side effects. When I have a patient who wants to lose weight (most should) and is reluctant about taking any other antineuropathic, they are often open to a trial of topamax.

I will mention that if they are a kidney stone former, watch out. They will churn them out like crazy if you start them on it.

Excellent dosing summary. I'm similar other than I start out with 50 QHS, then after several days add in a daytime dose and increase by 25mg increments.

Agree that 75mg BID is generally the sweet spot for pain relief without significant side effects. If no effect at 100mg BID, I generally try something else, unless patient is obese. Counterpoint is that Little old ladies often don't tolerate over 50 BID.

 

[Tapspatellas]

25% of patients on topamax lose weight.

75% do not.

Most?

Meaning most of my patients need to lose weight, definitely not that it works for most. I think it is more of an expectation for the patients and they may actually eat less and lose weight, if the side effects aren't too pronounced.

 

[SeniorWrangler]

Post traumatic neuropathies such as plexopathies or peripheral mononeuropathies from trauma like GSW, stretch or fall, MVA?

Yes, exactly. It stands out to me because it's the only thing that's worked for three brachial plexopathy patients and all of them were quite happy with it (not pain free but improved function and decreased opioid requirements). This is somewhere between anecdote and hunch but interesting.

 

[joshmir]

I dose Topiramate 25-200mg qhs only

Agree with above, and would add
I try tizanadine at night as well. Alpha 2 agonist

smartest pain doc I know, Stanford profess, believes desipramine is a way underrated TCA for pain

I’ve seen baclofen help some with pain too

don’t forget IV ketamine and IV lido, some people have meaningful and moderate term responses to 4 hour infusions

If maxed Outs on gabapentin, I E 3600 mg a day, and not having significant side effects, and having partial pain relief, that is the best reason to try to switch the Lyrica. I agree that there are some patients that Lyrica will work for that gabapentin will not, but I have no idea why.

Look up the UCSD paper on medical marijuana for pain, it has a bimodel response. I could see this being helpful for some people who have insomnia related to anxiety. Maybe magnesium at night is also indicated in the situation.

If you want to do a cool presentation for your residency staff, look up the work of the neurosurgeon at the Chicago medical school that published on the modulation of the limbic system via occipital nerve stimulation For fibromyalgia.

Also read about glial cell modulators, such as low-dose naltrexone.

Nucynta is also under-rated imho

 

[joshmir]

mexiletine, which is a sodium channel blocker that helps in neuropathic pain if an IV lidocaine infusion helps… Wouldn’t it be cute if the anti-arrhythmic mexiletine reduced the risk of arrhythmias from TCAs? I don’t think it does, but it may be useful To learn what medications might reduce the risk of arrhythmia from TCAs. And what conditions, Such as coronary artery disease versus CHF, predict arrhythmias with TCAs. I wonder if having a low normal serum magnesium level confers any level of increased risk from QT prolongation associated arrhythmias

 

[SommeRiver]

I dose Topiramate 25-200mg qhs only

Agree with above, and would add
I try tizanadine at night as well. Alpha 2 agonist

smartest pain doc I know, Stanford profess, believes desipramine is a way underrated TCA for pain

I’ve seen baclofen help some with pain too

don’t forget IV ketamine and IV lido, some people have meaningful and moderate term responses to 4 hour infusions

If maxed Outs on gabapentin, I E 3600 mg a day, and not having significant side effects, and having partial pain relief, that is the best reason to try to switch the Lyrica. I agree that there are some patients that Lyrica will work for that gabapentin will not, but I have no idea why.

Look up the UCSD paper on medical marijuana for pain, it has a bimodel response. I could see this being helpful for some people who have insomnia related to anxiety. Maybe magnesium at night is also indicated in the situation.

If you want to do a cool presentation for your residency staff, look up the work of the neurosurgeon at the Chicago medical school that published on the modulation of the limbic system via occipital nerve stimulation For fibromyalgia.

Also read about glial cell modulators, such as low-dose naltrexone.

Nucynta is also under-rated imho

Which Stanford professor, initials IC or SM?

 

[mariajane]

Anybody use lyrica plus gabapentin together synergistically

 

[deleted131481]

Do you realize this is a 4 yr old thread?

Maybe he wanted to make a strong first impression with a very first post? Also that post is copy and paste from the following:

Treatments for neuropathic pain

Neuropathic pain is a common condition characterised by subjective negative and positive symptoms that range from numbness to debilitating pain.

www.pharmaceutical-journal.com

Anybody use lyrica plus gabapentin together synergistically

I generally don't, but I have a handful usually from their neurologist that insist they work better together so I keep ir.

Lyrica has much better bioavailability especially at higher doses -something like 90% versus 30-60% for gaba as dose is escalated. This is my impression why anecdotally it seems to work better.

 

[lobelsteve]

Anybody use lyrica plus gabapentin together synergistically

I was taught that competitive uptake can occur and MOA same.

Data:

Is there a role for combined use of gabapentin and pregabalin in pain control? Too good to be true? - PubMed

Gabapentin (Neurontin ¹ ) and pregabalin (Lyrica ² ) are first- and second-generation α2δ ligands, respectively, and are both approved for use as adjunctive therapy in pain control. Although they do not bind to gamma-aminobutyric acid (GABA) receptors they have been...

pubmed.ncbi.nlm.nih.gov

I wouldn't do it.

 

[clubdeac]

mexiletine, which is a sodium channel blocker that helps in neuropathic pain if an IV lidocaine infusion helps… Wouldn’t it be cute if the anti-arrhythmic mexiletine reduced the risk of arrhythmias from TCAs? I don’t think it does, but it may be useful To learn what medications might reduce the risk of arrhythmia from TCAs. And what conditions, Such as coronary artery disease versus CHF, predict arrhythmias with TCAs. I wonder if having a low normal serum magnesium level confers any level of increased risk from QT prolongation associated arrhythmias

Yes, low magnesium increases risk of QT prolongation and subsequent arrhythmia from QT prolonging drugs

 

[Ligament]

I'm glad this post was resurrected. It is a great idea to update it. Sadly, my meds have not changed much in a long time:

Gabapentin and Cymbalta together always if not contraindicated. Seems synergistic.
If above fails, trial of Topamax 25 BID to start, then top out around 100BID if needed.
I never use TCAs, but should consider them for QHS sleep use.

 

[Ducttape]

I use more and more TCAs in the under 60 age group.

cheap, does provide insomnia benefit, and people can forget to take a dose and not complain "it doesn't work at all".

mexilitine has fallen out of favor, from my last curbside with cardiology, for almost all uses...

 

[Baron Samedi]

Had some success recently with Bupropion SR as a second-line treatment, especially in patients trying to quit smoking or lose weight.

Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain - PubMed

This placebo-controlled crossover trial showed that bupropion SR (150-300 mg daily) was effective and well tolerated for the treatment of neuropathic pain.

pubmed.ncbi.nlm.nih.gov