Depo outlawed

[nopain1234]

What steroid and dose is everyone using for their ESIs now? I’m not a huge fan of dex for interlams. Betamethasone 12mg? Kenalog 40mg?

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[callmeanesthesia]

Could you elaborate on this? I hadn’t heard anything about depo being banned.

 

[DOctorJay]

outlawed? link please

 

[Laryngospasm]

Depo 40mg

 

[Ferrismonk]

Dex. If that's unavailable, I'll use betamethasone.

Kenalog has specific warning not to use in epidural space fyi.

 

[paindoc007]

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.

 

[SSdoc33]

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.

Here is the link:

DepoMedrol No Longer Available for Epidural Use

People on Twitter are convinced this tomato looks like Larry Bird

This is for real. This tomato looks exactly like Bird.

ftw.usatoday.com

 

[lobelsteve]

Here is the link:

DepoMedrol No Longer Available for Epidural Use

People on Twitter are convinced this tomato looks like Larry Bird

This is for real. This tomato looks exactly like Bird.

ftw.usatoday.com

Tomato looks like Larry Bird. This is why we cannot use Depo.

 

[Pain Applicant1]

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.

 

[cowboydoc]

Tomato looks like Larry Bird. This is why we cannot use Depo.

I don’t follow leftist logic

 

[SageCraft]

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.

 

[macman]

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

 

[clubdeac]

My conspiracy theory mind thinks this is just another method of killing epidurals once and for all

 

[deleted875186]

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

 

[MD87]

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

This is correct. Interestingly (pathetically), if you actually read that citation (#16), the amounts are completely different than those listed.

 

[pmrmd]

Kenalog has a warning because Schering Plough requested it from the FDA. Legal decision not medical one. It’s as safe or unsafe as depo, depending on how you want to look at it.

 

[Ducttape]

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...

 

[SSdoc33]

for better or worse, it seems like we are moving towards no particulates in the epidural space

 

[RoloTomassi]

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.

Can you elaborate?

 

[Ferrismonk]

for better or worse, it seems like we are moving towards no particulates in the epidural space

Changed over 5 years ago...

 

[TIVAndy]

can someone show me a link about no kenalog in epidural space?

 

[Ferrismonk]

can someone show me a link about no kenalog in epidural space?

It's in the package insert.

"NOT FOR INTRAVENOUS, INTRADERMAL, INTRAOCULAR, EPIDURAL, OR INTRATHECAL USE"

https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/014901s038lbl.pdf

 

[nopain1234]

Sorry for the delay gents.

Am I missing something? Didn’t the new CMS guidelines say we can’t use depo anymore for ESIs?

 

[bedrock]

Sorry for the delay gents.

Am I missing something? Didn’t the new CMS guidelines say we can’t use depo anymore for ESIs?

If so, please provide a citation.
Otherwise it is just hearsay.

 

[deleted875186]

Sorry for the delay gents.

Am I missing something? Didn’t the new CMS guidelines say we can’t use depo anymore for ESIs?

That is not what the majority of us have heard. The LCD clearly gives max doses of depomedrol.

 

[pmrmd]

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...

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.

 

[nopain1234]

The new Medicare LCDs are saying no depo allowed.

Am I mistaken?

 

[nopain1234]

LCD - Epidural Steroid Injections for Pain Management (L39054)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

 

[MD87]

The new Medicare LCDs are saying no depo allowed.

Am I mistaken?

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…

 

[OffPiste]

The new Medicare LCDs are saying no depo allowed.

Am I mistaken?

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.

 

[nopain1234]

It’s fact. Read the guidelines. Can only use

Dex
Tria
Betameth

 

[nopain1234]

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.

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

 

[callmeanesthesia]

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

They give steroid equivalent doses but I don’t see any language that says other steroids will not be reimbursed.

 

[Ducttape]

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

no where in that statement does it say that you cannot use depomedrol.

you are making the assumption that depomedrol is not allowed.

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.

thanks for posting the link.

 

[SageCraft]

https://files.constantcontact.com/be15115b001/8a7ac8f1-7b21-4f4f-ad9e-f5a65fdbd6dd.pdf

See page 4. Manchikanti is looking to get this rectified.

 

[MitchLevi]

I did a 6 month trial of exclusively dex and the results weren’t there.

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.

 

[Dr. Ice]

I hear beta is close to as effective as depo..

 

[nopain1234]

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.

I use depo for TFESIs at lower lumbar segments. Never had any issues

 

[nopain1234]

I hear beta is close to as effective as depo..

80mg depo to 12mg beta?

When you mean effective you mean longevity or pain relief?

 

[Dr. Ice]

80mg depo to 12mg beta?

When you mean effective you mean longevity or pain relief?

Both..although this is what I hear from colleagues. Do not have personal experience with it

 

[Ducttape]

I use depo for TFESIs at lower lumbar segments. Never had any issues

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...

 

[MitchLevi]

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...

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.

 

[Ferrismonk]

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.

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:

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

 

[lobelsteve]

I use depo for TFESIs at lower lumbar segments. Never had any issues

1 in a million you paralyze someone.
Don’t be that guy.

 

[pmrmd]

Its more rare than 1:1,000,000.

 

[nopain1234]

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...

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.

 

[nopain1234]

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:

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

My anecdotal evidence >>> your studies results. The difference in patient results are profound

 

[ateria radicularis magna]

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.

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.

 

[MitchLevi]

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:

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

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).

 

[pmrmd]

We are going to be in a predicament with Medicare patients now. An ESI with dex isn’t lasting 3 months and many have lami at the area making IL impossible. It’s like getting set up for failure.