Botox for neuropathic pain

Started by drg123
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I've done it in CRPS as they'll sometimes have a focal dystonia, and then use the rest in a grid pattern after a nerve block proximal. If you're doing it for pure neuropathic pain, it would be cash pay or done for VA/etc.

Key thing here is to just do SQ injections as you're not trying to get into the muscle at all.
 
Not sure if this is helpful, but years ago, I spoke with the medical science liaison for xeomin

He was a pharmacist at the VA

He said that they had done an internal data review at the VA and found that for what they had used xeomin for, the efficacy was non-inferior to Botox, at a conversion rate of 1:1 unit

If that guy is still the medical science liaison, he may be able to query their database for that

But then, again, he would still be the medical science liason and perhaps be biased in favor of xeomin
 
Anyone ever have success doing off label with a letter of medical necessity to payor? the local rep suggested I might try this, citing studies and such. I feel like this is something the companies should be interested in getting on-label indication for. Huge number of patients would be candidates and it's safe and fast.
 
drg123 said:
Thanks for the intel. Sorry to hear it didn't pan out. I think NNT is still something like 3. So checks out.
Click to expand...
Umm, WTH?

1716041196363.png



Number Needed to Treat (NNT) — Centre for Evidence-Based Medicine (CEBM), University of Oxford

The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.).
www.cebm.ox.ac.uk www.cebm.ox.ac.uk
 
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lobelsteve said:
Umm, WTH?

View attachment 386949


Number Needed to Treat (NNT) — Centre for Evidence-Based Medicine (CEBM), University of Oxford

The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.).
www.cebm.ox.ac.uk www.cebm.ox.ac.uk
Click to expand...
I am using it in this context, not the one you cite above. It can be used both for benefits and harms

Gabapentin for Chronic Neuropathic Pain – TheNNT

thennt.com thennt.com
primarycarenotebook.com

Number needed to treat (NNT) – Primary Care Notebook

NNT defined as the number of patients needed to treat for one to benefit, with example calculation from event rates and risk reduction.
primarycarenotebook.com

And I stand corrected. Here is the source. I said 3. It's apparently 1.9.
1716043399463.png



1.Finnerup, N. B. et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurology 14, 162–173 (2015).
 

Botulinum toxin type A​

Six RCTs evaluated the efficacy of a single administration of BTX-A (50–200 units subcutaneously in the painful area) in peripheral neuropathic pain. The smaller studies had a positive primary outcome (NNT of 1·9 (1·5–2·4) for four studies) with a very low placebo effect, but one large unpublished study was negative. Safety was generally excellent.


The NNT you quoted is not including the large trial that was negative.
 
A better study/review:

www.ncbi.nlm.nih.gov

Botulinum Toxin for the Treatment of Neuropathic Pain

Botulinum toxin (BoNT) has been used as a treatment for excessive muscle stiffness, spasticity, and dystonia. BoNT for approximately 40 years, and has recently been used to treat various types of neuropathic pain. The mechanism by which BoNT acts on neuropathic ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
drg123 said:
I am using it in this context, not the one you cite above. It can be used both for benefits and harms

Gabapentin for Chronic Neuropathic Pain – TheNNT

thennt.com thennt.com
primarycarenotebook.com

Number needed to treat (NNT) – Primary Care Notebook

NNT defined as the number of patients needed to treat for one to benefit, with example calculation from event rates and risk reduction.
primarycarenotebook.com

And I stand corrected. Here is the source. I said 3. It's apparently 1.9. View attachment 386950


1.Finnerup, N. B. et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurology 14, 162–173 (2015).
Click to expand...


Not a knock on you, but when the authors report an NNT of 4.3 for “Strong Opioids”…the underlying methodology of this paper immediately takes a hit
 
it should be noted in your meta-analysis that there were 6 botox studies, total 137 patients, significantly lower than any of the other treatments, and this was the only interventional treatment.

like lobel stated:

Botulinum toxin type A​

Six RCTs evaluated the efficacy of a single administration of BTX-A (50–200 units subcutaneously in the painful area) in peripheral neuropathic pain. The smaller studies had a positive primary outcome (NNT of 1·9 (1·5–2·4) for four studies) with a very low placebo effect, but one large unpublished study was negative. Safety was generally excellent.
Click to expand...
that NNT is only for the smaller studies, did not include the large unpublished one.

the strength of recommendation was weak for use of botox and were recommended as a 3rd line agent in peripheral neuropathy only.

and in their lengthy summary, botox is not mentioned at all.
 
Ducttape said:
it should be noted in your meta-analysis that there were 6 botox studies, total 137 patients, significantly lower than any of the other treatments, and this was the only interventional treatment.

like lobel stated:

that NNT is only for the smaller studies, did not include the large unpublished one.

the strength of recommendation was weak for use of botox and were recommended as a 3rd line agent in peripheral neuropathy only.

and in their lengthy summary, botox is not mentioned at all.
Click to expand...
If they included the larger unpublished study (suppressed by Allergan?), what do you think the analysis would show?
 
seems appropriate to try after they have failed the first and second line treatments.


these patients did fail first and second line treatments, right?


and btw, the lancet article as you correctly posted was a review. id be less likely to use that as basis for decision making than RCTs and other studies.

the first article was based on a total of 66 total patients. not a huge sample size. efficacy was primarily with 2 injections. studied to 24 weeks.

6.5 mean pain intensity at baseline down to 4.6 for botox, compared to 6.4 to 5.8 for placebo.
 
On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks
 
mohandess said:
On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks
Click to expand...
I have patients that I inherited from a previous provider who receive botox for neck pain diagnosed as "cervical dystonia". I felt a little uncomfortable continuing with the procedures as, at least in my opinion, they don't have true dystonia, but the patients swear by them and have done really well so I just continued them. Not a lot but enough to believe that it can be effective.
 
mohandess said:
On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks
Click to expand...
Is the Neurologist doing TPI's first, and if successful but not having sustained long term pain relief, then incorporating the botox?
 
Dansk2011 said:
I have patients that I inherited from a previous provider who receive botox for neck pain diagnosed as "cervical dystonia". I felt a little uncomfortable continuing with the procedures as, at least in my opinion, they don't have true dystonia, but the patients swear by them and have done really well so I just continued them. Not a lot but enough to believe that it can be effective.
Click to expand...

What technique do you use to confirm your location for this? EMG? US?
 
mohandess said:
On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks
Click to expand...
Tried it when I worked at the VA. Usually it didn’t work

If you do a pubmed search of Botox for myofascial pain most studies show no benefit
 
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