Depo outlawed

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Cmon dude. What a clickbait title. I haven’t heard of any outlaw of it. If there is, provide a link and info so we can discuss.
 
paindoc007 said:
Cmon dude. What a clickbait title. I haven’t heard of any outlaw of it. If there is, provide a link and info so we can discuss.
Click to expand...

Here is the link:

DepoMedrol No Longer Available for Epidural Use
ftw.usatoday.com

People on Twitter are convinced this tomato looks like Larry Bird

You say tomato. I say Larry Bird's doppelgänger. A photo of a tomato made rounds on the internet on Sunday, and that was, in part, because that fruit (yes, a tomato is a fruit) looked not-so-distantly related to Bird. In fact, the resemblance was staggeringly obvi
ftw.usatoday.com
 
SSdoc33 said:
Here is the link:

DepoMedrol No Longer Available for Epidural Use
ftw.usatoday.com

People on Twitter are convinced this tomato looks like Larry Bird

You say tomato. I say Larry Bird's doppelgänger. A photo of a tomato made rounds on the internet on Sunday, and that was, in part, because that fruit (yes, a tomato is a fruit) looked not-so-distantly related to Bird. In fact, the resemblance was staggeringly obvi
ftw.usatoday.com
Click to expand...
Tomato looks like Larry Bird. This is why we cannot use Depo.
 
I can't even get depo as it's back-ordered. I use betamethasone for epidurals and kenalog for joints. PF saline is now back-ordered too. Not sure what I'm going to do about that one.
 
Our group has also been informed to stop using any Depo in the epidural space. Dr. Manchikanti addresses this in his recent ASIPP presentation regarding the new LCD.
 
It only makes sense that is Kenalog and Depo would both be unwise for TFESI. For ILESI it shouldn't matter. It never made sense that Kenalog had special FDA warning and Depo did not
 
My conspiracy theory mind thinks this is just another method of killing epidurals once and for all
 
Am I missing something? The lcd says depo 80 mg is max dose?

  1. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16
 
dipriMAN said:
Am I missing something? The lcd says depo 80 mg is max dose?

  1. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 80 mg of methylprednisolone, 12 mg of betamethasone, or 15 mg of dexamethasone per session.16
Click to expand...

This is correct. Interestingly (pathetically), if you actually read that citation (#16), the amounts are completely different than those listed.
 
I'm not so sure of the veracity of this comment. I do not remember any Big Pharma company approaching the FDA to put on a warning. First, they wouldn't have to approach the fda. They could just put the warning in themselves..

Second, kenalog is made by Bristol-Myers...
 
for better or worse, it seems like we are moving towards no particulates in the epidural space
 
Ducttape said:
I'm not so sure of the veracity of this comment. I do not remember any Big Pharma company approaching the FDA to put on a warning. First, they wouldn't have to approach the fda. They could just put the warning in themselves..

Second, kenalog is made by Bristol-Myers...
Click to expand...
Memory is such a funny thing. I forgot it was BMY and not Schering. You don't remember it ever happening. If you want an FDA label, you have to tell them.

Regulatory history, page 12. BMY submitted to the FDA after catastrophic events. I don't post things unless I know they are true, bro.
 

Attachments

nopain1234 said:
The new Medicare LCDs are saying no depo allowed.

Am I mistaken?
Click to expand...

Can you post a link for where you saw this? From reading the responses to your post so far, it seems no one has any idea what you’re talking about…
 
nopain1234 said:
The new Medicare LCDs are saying no depo allowed.

Am I mistaken?
Click to expand...
Some of the LCD’s reference “recommended” steroids and maximum doses (dexamethasone, betamethasone, tiramcinolone). It is interesting that triamcinolone is included considering the black box FDA warning against epidural use. Depomedrol is not included as a “recommended” steroid in some LCD’s BUT it is not specifically disallowed. The language seems to imply that the goal is to use the lowest effective dose. We need to be very careful about stating that something is “forbidden” when that is not the case.
Many of us have used depomedrol for years.I see no reason why it cannot continue to be used for interlaminars. I do not agree with ASIPP interpretation here.
 
OffPiste said:
Some of the LCD’s reference “recommended” steroids and maximum doses (dexamethasone, betamethasone, tiramcinolone). It is interesting that triamcinolone is included considering the black box FDA warning against epidural use. Depomedrol is not included as a “recommended” steroid in some LCD’s BUT it is not specifically disallowed. The language seems to imply that the goal is to use the lowest effective dose. We need to be very careful about stating that something is “forbidden” when that is not the case.
Many of us have used depomedrol for years.I see no reason why it cannot continue to be used for interlaminars. I do not agree with ASIPP interpretation here.
Click to expand...

Well, I too use a ton of depo and am a bit taken back. I did a 6 month trial of exclusively dex and the results weren’t there.

I guess we will know when people do or do not get reimbursed for ESIs using depo
 
nopain1234 said:
Well, I too use a ton of depo and am a bit taken back. I did a 6 month trial of exclusively dex and the results weren’t there.

I guess we will know when people do or do not get reimbursed for ESIs using depo
Click to expand...
They give steroid equivalent doses but I don’t see any language that says other steroids will not be reimbursed.
 
  1. Steroid dosing should be the lowest effective amount. It is recommended not to exceed 80 mg of triamcinolone, 12 mg of betamethasone, and 15 mg of dexamethasone per session.16
Click to expand...
no where in that statement does it say that you cannot use depomedrol.

you are making the assumption that depomedrol is not allowed.

pmrmd said:
Memory is such a funny thing. I forgot it was BMY and not Schering. You don't remember it ever happening. If you want an FDA label, you have to tell them.

Regulatory history, page 12. BMY submitted to the FDA after catastrophic events. I don't post things unless I know they are true, bro.
Click to expand...
thanks for posting the link.
 
nopain1234 said:
I did a 6 month trial of exclusively dex and the results weren’t there.
Click to expand...
Agreed.

Depo ILESI is the most effective ESI I do, and IMO clearly outperform TFESI with dex in patients with stenosis, chronic low back and radicular pain.

The surgeons in my group do TFESI with Depo 80mg + 2cc bupi 0.25% and if I see that pt and do a repeat TFESI with dex, despite my better technique they commonly ask why mine didn't work as long.

I don't do TFESI with particulate.
 
MitchLevi said:
Agreed.

Depo ILESI is the most effective ESI I do, and IMO clearly outperform TFESI with dex in patients with stenosis, chronic low back and radicular pain.

The surgeons in my group do TFESI with Depo 80mg + 2cc bupi 0.25% and if I see that pt and do a repeat TFESI with dex, despite my better technique they commonly ask why mine didn't work as long.

I don't do TFESI with particulate.
Click to expand...

I use depo for TFESIs at lower lumbar segments. Never had any issues
 
Ducttape said:
the issue for depo as a particulate is there is concern for acute paralysis due to vertebral artery injury.

"Never had any issues" is a comment that i imagine lawyers salivate to hear...
Click to expand...

Spine surgeons salivate hearing about epidurals offering 4-6 weeks of relief.

The reality is virtually every ILESI should be done with particulate bc the effect tends to last longer than dexamethasone.

The risk of anything catastrophic happening from an ILESI containing Depo is virtually zero.

The immediate and long-term risk of a lumbar fusion is high.

Of course, I've had plenty of failed ILESI with Depo.
 
MitchLevi said:
Spine surgeons salivate hearing about epidurals offering 4-6 weeks of relief.

The reality is virtually every ILESI should be done with particulate bc the effect tends to last longer than dexamethasone.

The risk of anything catastrophic happening from an ILESI containing Depo is virtually zero.

The immediate and long-term risk of a lumbar fusion is high.

Of course, I've had plenty of failed ILESI with Depo.
Click to expand...

1. All things being equal, I'd rather a spine surgeon salivate than a lawyer.

2. There is minimal to no evidence that epidural steroids delay time to surgery at all, let alone particulate vs non-particulate.

3. Particulates providing longer relief is not what the evidence shows. In fact, study after study shows no difference. Here's a recent one:
pubmed.ncbi.nlm.nih.gov

Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety - PubMed

There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Ducttape said:
the issue for depo as a particulate is there is concern for acute paralysis due to vertebral artery injury.

"Never had any issues" is a comment that i imagine lawyers salivate to hear...
Click to expand...
I’m aware of the risk, however, my partner who’s practiced 30 years plus has been without any adverse event. My attendings never had any adverse events. (Although were forced to change to dex due to being in academics) If the artery of adamkwiectz doesn’t project down to L4 or L5 I don’t see the risk. I’d never perform one at L3 or above.
 
Ferrismonk said:
1. All things being equal, I'd rather a spine surgeon salivate than a lawyer.

2. There is minimal to no evidence that epidural steroids delay time to surgery at all, let alone particulate vs non-particulate.

3. Particulates providing longer relief is not what the evidence shows. In fact, study after study shows no difference. Here's a recent one:
pubmed.ncbi.nlm.nih.gov

Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety - PubMed

There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
My anecdotal evidence >>> your studies results. The difference in patient results are profound
 
nopain1234 said:
I’m aware of the risk, however, my partner who’s practiced 30 years plus has been without any adverse event. My attendings never had any adverse events. (Although were forced to change to dex due to being in academics) If the artery of adamkwiectz doesn’t project down to L4 or L5 I don’t see the risk. I’d never perform one at L3 or above.
Click to expand...

Every day people inject depo into me. Usually just a little dribble. But when someone pumps in 40 of depo, I close my eyes and wait for the end to come. One of these days I’ll meet my maker.
 
Ferrismonk said:
1. All things being equal, I'd rather a spine surgeon salivate than a lawyer.

2. There is minimal to no evidence that epidural steroids delay time to surgery at all, let alone particulate vs non-particulate.

3. Particulates providing longer relief is not what the evidence shows. In fact, study after study shows no difference. Here's a recent one:
pubmed.ncbi.nlm.nih.gov

Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety - PubMed

There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
1. Why would putting Depo in an ILESI result in your being cross-examined by an attorney? Anatomically, what are my risks and what's the likelihood something catastrophic happens?

All of the pain doctors around me use Depo in their TFESI...I do not. They all use Depo in their ILESI as well. I read their notes.

2. Ludicrous statement made by someone who thinks reality exists in the data. Why should I use a parachute when jumping out of an airplane? Show me the data.

What do you do for a living? I keep people off the operating table with selective use of spine interventions. I send maybe 1-4 pts per quarter to our spine surgeons in-house. The procedures most likely to result sustained benefit (3 or more months) are the bilateral L4-S1 facet joint RFA and the L4-5 ILESI with 80mg Depo + 2.5cc saline + 0.5cc lidocaine 2%.

These results simply do not occur with TFESI using dexamethasone because I do them all the time and it rarely happens.

3. Not about to sit here and go through a meta so I can have some conversation on SDN with a dude who made the previous statement (point 2 above).
 
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