AED's.....hepatic vs renal

[Doctodd]

For your diabetic patients with renal insufficiency(or worse), which AED are you getting better results with for neuropathic pain since you cant go too high on the Neurontin or Lyrica? Gabitril, Topamax, Lamictal?.....others?

T

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[Tenesma]

get a nephrology consult... and let them decide

 

[Doctodd]

true....but not what im asking. You are right i get the renal guys sometimes changing my neurontin 100mg qhs dose to qod(every other day) so they feel like they have done something maybe?...i dont know if it makes that much of a difference. But i respect their order.

What i want to know is which med you get the best results with? Cymbalta might be hepatic...not sure off the top of my head....need to look in my pharmacopeia. Just want to know your own personal experiences. Formulary might have something to do with it too....you guys tell me. The busier i get, the more failed neurontin/lyrica patients i get, and that is the reason for the question.

To be more specific, i have a patient c/o bilateral leg burning pain with hx of CVA(occipital, cerebellar, and other small vessel), poorly controlled DM, surgically hypothyroid secondary to CA, obese patient on roxi 30mg q4hrs like candy. She isnt responding to 800 Neurontin qid and lyrica 100 tid. I started her on topamax and a low dose of dilaudid. She has 3 reasons right there for the neuropathic pain(central pain, DM, hypothyroid).

T

 

[stim4u]

Central pain=pain pump.

you can continue to rotate meds, and neuropathic medications, assuming you can convice her not to take the roxy q4-6. And as much as I do not like to implant pain pumps, consider a trial with dilaudid +/-clonidine/bupiv/ and maybe ziconitide. otherwise duragesic (lower dose) and methadone (hepatobiliary)are your alternative medications.

does not seem like a stim trial would palliate the majority of her pain..

 

[drusso]

true....but not what im asking. You are right i get the renal guys sometimes changing my neurontin 100mg qhs dose to qod(every other day) so they feel like they have done something maybe?...i dont know if it makes that much of a difference. But i respect their order.

What i want to know is which med you get the best results with? Cymbalta might be hepatic...not sure off the top of my head....need to look in my pharmacopeia. Just want to know your own personal experiences. Formulary might have something to do with it too....you guys tell me. The busier i get, the more failed neurontin/lyrica patients i get, and that is the reason for the question.

To be more specific, i have a patient c/o bilateral leg burning pain with hx of CVA(occipital, cerebellar, and other small vessel), poorly controlled DM, surgically hypothyroid secondary to CA, obese patient on roxi 30mg q4hrs like candy. She isnt responding to 800 Neurontin qid and lyrica 100 tid. I started her on topamax and a low dose of dilaudid. She has 3 reasons right there for the neuropathic pain(central pain, DM, hypothyroid).

T

So here's my take: There is no scientific answer. Finding the right AED is like finding a good pair of pants...you just have to try a lot on.

I think the number one mistake people make is premature termination before a patient has actually been trialed on a therapeutic dose. I would just systematically pick one AED at a time, optimize it, decide if it works, if not then taper, switch, start over.

What about a TCA? They're old school, but they work.

Topamax and tramadol in combination can have good synergy for NP.

Is the patient a candidate for SCS or intrathecal medication?

 

[Doctodd]

medicaid patient......i inherited this patient at the rehab hospital. To d/c the other meds would take time and im trying to do as much as possible in a short time. As of right now she isnt participating in PT cuz of the "pain". Of course she also has the usual anx/dep. Im using as much Jedi Mind Trick as possible too. ;-)

 

[drusso]

medicaid patient......i inherited this patient at the rehab hospital. To d/c the other meds would take time and im trying to do as much as possible in a short time. As of right now she isnt participating in PT cuz of the "pain". Of course she also has the usual anx/dep. Im using as much Jedi Mind Trick as possible too. ;-)

Oh, I get it now: So, she gets methadone and renally-dosed gabapentin +/- dilaudid or oxycodone for BTP. Add Effexor. Add scheduled APAP. Consider TENS Unit...

 

[Tenesma]

if portenoy had a say he would be recommending fentora -

i would wean the narcotics

i would be weary of an implanted pump in a diabetic with multiple co-morbidities - very high risk of failure/infection

i would recommend a full neuro eval including a trial of my 2 miracle drugs
- Vitamin B12 at high doses or Evening Primrose Oil.... i have had some impressive results with these

 

[lobelsteve]

if portenoy had a say he would be recommending fentora -

i would wean the narcotics

i would be weary of an implanted pump in a diabetic with multiple co-morbidities - very high risk of failure/infection

i would recommend a full neuro eval including a trial of my 2 miracle drugs
- Vitamin B12 at high doses or Evening Primrose Oil.... i have had some impressive results with these

Add in Drisdol and Armour Thyroid and you will make a slug into the Terminator.