Advice Please

[jetproppilot]

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My father in law, a vet, has a radiculopathy I've treated in the past with a cuppla ESI's (depomedrol 80mg) with pretty good results. The VA he goes to doesnt do them, so I've done 2 ESIs in his dining room.

He's had pretty good results (months of amelioration of symptoms), but now his symptoms are back.

An MD he sees at the VA said he read about adding elavil/nortryptiline/carbamazapine to the epidural injection.

I've never done this. Any attendings out there know anything about this? Any literature references?

 

[Tenesma]

1) don't do them in your dining room

2) have them done under fluoro by a trained pain physician

3) no evidence supporting the use of TCAs or anticonvulsants in the epidural space.... there is some whack job in LA who adds Enbrel... wouldn't do it.

4) does he even have a complete work-up?

 

[jetproppilot]

1) don't do them in your dining room

2) have them done under fluoro by a trained pain physician

3) no evidence supporting the use of TCAs or anticonvulsants in the epidural space.... there is some whack job in LA who adds Enbrel... wouldn't do it.

4) does he even have a complete work-up?

Thanks for the reply, Ten.

Unfortunately, reality is reality. He doesnt have access ($$) to a pain doc, the VA offers limited care/workups. It was either me doing them in the dining room, or nothing at all.

Thanks for the "no literature supporting epidural space TCAs" comment.

 

[zippy2u]

Dr. moneybags, Have the guy see a pain doc. You pay the tab. You score bigtime with your wife because you takin' care of her Daddy. You're the Elvis of the family so act like it----TCB Regards, ---Zip

 

[jetproppilot]

Dr. moneybags, Have the guy see a pain doc. You pay the tab. You score bigtime with your wife because you takin' care of her Daddy. You're the Elvis of the family so act like it----TCB Regards, ---Zip

As soon as I hit the "submit reply button, I knew that was coming.

And youre right, Zip.

And I've offered. Very proud man. Doesnt willfully take handouts..(although I sent a 4K Dell computer to his house a cuppla years ago...Katrina recently ate it up)

Guess I need to just set it up with my pain buddy and tell the dude to be there.

 

[Noyac]

No epidural TCA's here Jet.

If he gets relief from the ESI's in the kitchen then continue. But these ESI's need to last him for some time. If you do 3 in a 6 week span (1-2 weeks apart) and he is functional for > 6 months then great. If they don't last long enough then he probably has some spinal stenosis ( foraminal narrowing) that is too tight. Do them with 80 mg depo. 10 cc PF normal saline and NO local (complications come from local mostly with the exception of intrathecal steroids- arachnoiditis). Add some Elavil (5mg) at night for sleep (cheap) and see how long this lasts. If his insurance will cover neurontin you can add that to the regimen. Slowly work up to 1800 mg per day over 2-3 weeks. If all this doesn't help, he may benefit from transforaminal injections.

If his back hurts when extending more than flexing then he may need facet injections.

PS: an MRI would be nice, however.

 

[jetproppilot]

No epidural TCA's here Jet.

If he gets relief from the ESI's in the kitchen then continue. But these ESI's need to last him for some time. If you do 3 in a 6 week span (1-2 weeks apart) and he is functional for > 6 months then great. If they don't last long enough then he probably has some spinal stenosis ( foraminal narrowing) that is too tight. Do them with 80 mg depo. 10 cc PF normal saline and NO local (complications come from local mostly with the exception of intrathecal steroids- arachnoiditis). Add some Elavil (5mg) at night for sleep (cheap) and see how long this lasts. If his insurance will cover neurontin you can add that to the regimen. Slowly work up to 1800 mg per day over 2-3 weeks. If all this doesn't help, he may benefit from transforaminal injections.

If his back hurts when extending more than flexing then he may need facet injections.

PS: an MRI would be nice, however.

Thanks Noy.

 

[PGY2]

I've started using Lyrica instead of neurontin - start at 75mg po qhs for 3 days then up to BID. Easier to take a drug BID than TID or QID as with neurontin. Good luck.

By the way, dont let the screen name fool you, I was a PGY2 about 5 years ago.

 

[Noyac]

I've started using Lyrica instead of neurontin - start at 75mg po qhs for 3 days then up to BID. Easier to take a drug BID than TID or QID as with neurontin. Good luck.

By the way, dont let the screen name fool you, I was a PGY2 about 5 years ago.

Great, to hear PGY2. Is lyrica a gabapentin type med? Does insurance cover it? If not, I'm sure its expensive, as neurontin can be. 👍

 

[rexed]

Great, to hear PGY2. Is lyrica a gabapentin type med? Does insurance cover it? If not, I'm sure its expensive, as neurontin can be. 👍

Lyrica (pregabalin) is approved for seizures, PHN & diabetic neuropathy in the US. Apprently it's been available outside of the US for a while. Has a different molecular structure (obviously) than neurontin which lends itself to a lower side effect profile and easier titration.
From speaking with a rep, they said that it should be priced comparitively to neurontin (equiv doses). Funny thing is Pfizer owns neurontin too which recently is going/went generic...

We've been prescribing lyrica in a handful of patients....when it works it works (like neurontin) too soon to see any major differences though...

 

[sdn1977]

Here in CA Lyrica is expensive - I've dispensed it 4 times to 4 different patients - only on the manufacturer's "coupon". All had different insurance - all required preauthorization - none were ever approved. Apparently there is no "compelling" difference in effectiveness between it and gabapentin, which is indeed now generic and very inexpensive. A month's supply is about $145 in CA....expensive for those folks who suffer chronic pain which usually involves multiple medications. My take is this is similar to the Prilosec/Nexium; Claritin/Clarinex; etc drug marketing...tweak the chemical and remarket when the original drug goes off patent. No real change in effectiveness - but it does attempt to "hold" the market. And...for these pain folks - there is not much out there that works consistently for the long term. But...there are new drugs in the pipeline which may offer unique benefits in the future.......

 

[PGY2]

Here in CA Lyrica is expensive - I've dispensed it 4 times to 4 different patients - only on the manufacturer's "coupon". All had different insurance - all required preauthorization - none were ever approved. Apparently there is no "compelling" difference in effectiveness between it and gabapentin, which is indeed now generic and very inexpensive. A month's supply is about $145 in CA....expensive for those folks who suffer chronic pain which usually involves multiple medications. My take is this is similar to the Prilosec/Nexium; Claritin/Clarinex; etc drug marketing...tweak the chemical and remarket when the original drug goes off patent. No real change in effectiveness - but it does attempt to "hold" the market. And...for these pain folks - there is not much out there that works consistently for the long term. But...there are new drugs in the pipeline which may offer unique benefits in the future.......

Here in Ohio, the cost is similar to that of generic gabapentin. The ease of dosing however makes it worth the small extra cost.