Depo

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Dr. Ice

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My practice is telling me depo has been discontinued from all distributors. Is anyone else encountering this issue?
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Dr. Ice said:
My practice is telling me depo has been discontinued from all distributors. Is anyone else encountering this issue?
Click to expand...
Wasn't told discontinued, but backorder? who knows, we've switched to kenolog
 
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Depomedrol package insert​


WARNINGS​

Serious Neurologic Adverse Reactions With Epidural Administration​

Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.

(essentially same as Kenalog insert)
 
Nodolor said:

Depomedrol package insert​


WARNINGS​

Serious Neurologic Adverse Reactions With Epidural Administration​

Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke. These serious neurologic events have been reported with and without use of fluoroscopy. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.

(essentially same as Kenalog insert)
Click to expand...
That is true, but not the relevant section.

KENALOG®-40 INJECTION triamcinolone acetonide injectable suspension, USP
NOT FOR USE IN NEONATES CONTAINS BENZYL ALCOHOL For Intramuscular or Intra-articular Use Only
NOT FOR INTRAVENOUS, INTRADERMAL, INTRAOCULAR, EPIDURAL, OR INTRATHECAL USE



DepoMedrol just states Not for IV use. All steroids are off-label for epidural use.
 
Are any of the generic methylprednisolone formulations preservative free? Just asking out of curiosity, don’t want to start a big argument about if preservative free is necessary in the epidural space.
 
essentially the only preservative free non-compounded steroid available is dexamethasone.

i strongly urge you to NOT buy compounded steroid by some pharmacy......


fwiw, dexamethasone has preservative - citrate. given quirks of the FDA, it is considered a food additive and not a preservative.
 
So the label for Kenalog says not for epidural use but who here feels it really is unsafe for ESI? Bristol-Myers asked the FDA for that labeling to avoid lawsuits.
 
pmrmd said:
So the label for Kenalog says not for epidural use but who here feels it really is unsafe for ESI? Bristol-Myers asked the FDA for that labeling to avoid lawsuits.
Click to expand...
I only use Dex for all epidurals and cervical injections. Studies show noninferiority.

Also, doesn't matter what I think, I don't want to be on the stand after some bad outcome with a opposing lawyer pointing to a "Do not use" warning and I used it anyway.
 
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This should not be in the public forum
 
Ferrismonk said:
I only use Dex for all epidurals and cervical injections. Studies show noninferiority.

Also, doesn't matter what I think, I don't want to be on the stand after some bad outcome with a opposing lawyer pointing to a "Do not use" warning and I used it anyway.
Click to expand...
Not true at all. Studies in this country show non-inferiority for radic with a low benchmark for success. Global studies shows inferiority for stenosis with dex compared to depo preparations. I've cited them in previous posts.

Also, be a doctor and answer a simple medical question. Is it more unsafe than depo medrol?
 
pmrmd said:
Not true at all. Studies in this country show non-inferiority for radic with a low benchmark for success. Global studies shows inferiority for stenosis with dex compared to depo preparations. I've cited them in previous posts.

Also, be a doctor and answer a simple medical question. Is it more unsafe than depo medrol?
Click to expand...
Agree with you for radic, but studies also show epidural steroids don't work for stenosis without radic.

And no, DepoMedrol is just as unsafe as Kenalog in my opinion. It's the particulate steroid issue. Hence why I use dex.
 
Ferrismonk said:
Agree with you for radic, but studies also show epidural steroids don't work for stenosis without radic.

And no, DepoMedrol is just as unsafe as Kenalog in my opinion. It's the particulate steroid issue. Hence why I use dex.
Click to expand...
Point being using Depomedrol is no different than using Kenalog. No one could say it affords more risk. As far as the 1 in 10m risk of injury from particulate, I feel we are putting patients in greater risk for failure of conservative care and more likely to get surgery--and more likely to have bad outcome from surgery--than risk of injury with particulate steroid.

Who is doing ESI for stenosis without much leg pain?
 
pmrmd said:
Point being using Depomedrol is no different than using Kenalog. No one could say it affords more risk. As far as the 1 in 10m risk of injury from particulate, I feel we are putting patients in greater risk for failure of conservative care and more likely to get surgery--and more likely to have bad outcome from surgery--than risk of injury with particulate steroid.

Who is doing ESI for stenosis without much leg pain?
Click to expand...
that rationale only makes sense if you can prove the depo preparations work better than dex. we don't have that data
 
actually, no we dont.

the data outside the US is inconsistent and, depending on where it is from, may not meet standards of US based studies.



the reverse argument can be used. there is no data to suggest that using kenalog over dex or depo prevents surgical intervention.
 
Ducttape said:
actually, no we dont.

the data outside the US is inconsistent and, depending on where it is from, may not meet standards of US based studies.



the reverse argument can be used. there is no data to suggest that using kenalog over dex or depo prevents surgical intervention.
Click to expand...
I see. European data is inferior and anything from Asia is inconsistent. The meta-analysis of 50% success rate studies we find on PubMed is your idea of consistency and quality.

You guys must have treated the same patients with different epidural preparations at different times and noted their outcomes. They aren't equivalent.
 
pmrmd said:
I see. European data is inferior and anything from Asia is inconsistent. The meta-analysis of 50% success rate studies we find on PubMed is your idea of consistency and quality.

You guys must have treated the same patients with different epidural preparations at different times and noted their outcomes. They aren't equivalent.
Click to expand...
i think the white stuff probably works a little better. but i have no real data to back that up.

as far as the europeans? this should answer your question:

 
pmrmd said:
I see. European data is inferior and anything from Asia is inconsistent. The meta-analysis of 50% success rate studies we find on PubMed is your idea of consistency and quality.

You guys must have treated the same patients with different epidural preparations at different times and noted their outcomes. They aren't equivalent.
Click to expand...
Post the data.

No more hiding behind "I posted it before so it must be true." No more supposition.

Post it that specifically shows that it is clinically superior and we will look at those studies, and if they are appropriate, change our minds.

Fwiw I never said where the data is specifically from as being the concern. And I have consistently stated that meta analysis is not as rubies as a true study. Drusso derides them as GIGO and there may be some validity to many of these studies as such.
 
Cureus 2020 Feb 26;12(2):e7104

Eur Radiol 2019 Jul;29(7):3379-3389.

Eur Radiol 27, 1505–1511 (2017)

Reg Anesth Pain Med Nov-Dec 2011;36(6):572-8--Hey this study says dex is great...if you call a 30% improvement great. My patients would complain.

I'm only talking stenosis here, not acute radic from HNP.
 
Cureus -
1. retrospective study so not high level of evidence
2. only 1 doctor did the injections.
3. the "tested" individuals were 1/3rd of the total number of injected patients, as these were the ones that did not get significant response.
4. this was not a study that compared dex to any other medication. it was a retrospective study that used triamcinolone for the second injection in the 1/3 of patients who had failed the first.

Eur Rad 2019
1. observational retrospective study
2. did compare dex to triamcinolone
3. found benefit of triamcinolone over dex in severe pain but not in mild to moderate pain.
4. only followed 4 weeks out and no determination it prevented surgery.
5. of note, these were ESI (not TF)

Eur Rad 27
1. not a blinded or randomized study. just sequential patients.
2. there was significant decrease in NRS and improved patient global impression of change scale with particulates at 1 week and 1 month
3. no long term data included otherwise
4. CT guided epidurals.

Reg Anesth
1. this was a dose ranging study. it was an RCT. but no placebo, and no kenalog or depo. only dex. shows no real difference in dosage.

you cant say kenalog would have been so much better, if no kenalog (or any particulate steroid) was used in the study.


in summary:
1. 2 of the studies suggested that 1 month out the particulate steroid was better.

2. 3 of the studies were low level evidence (Level 3). the other study did not involve particulates

3. there was no long term efficacy of any of the studies, nor any evidence suggesting changes in long term treatment or avoidance of surgery.

4. of note, one of the articles specifically pointed out that the difference could very likely be due to systemic effects from steroid and not the specific steroid itself (Eur Rad 27)

5. no study compared depo to kenalog.





in full disclosure i still use depo particulate steroid for ESI, and only dex for TF.

i see nothing to suggest that using an FDA black box labelled drug (kenalog) is superior or indicated over drugs without such a black box warning (depo), but thats me.
 
the white stuff is a tick better.

but more dangerous with TFESI
 
Ducttape said:
Cureus -
1. retrospective study so not high level of evidence
2. only 1 doctor did the injections.
3. the "tested" individuals were 1/3rd of the total number of injected patients, as these were the ones that did not get significant response.
4. this was not a study that compared dex to any other medication. it was a retrospective study that used triamcinolone for the second injection in the 1/3 of patients who had failed the first.

Eur Rad 2019
1. observational retrospective study
2. did compare dex to triamcinolone
3. found benefit of triamcinolone over dex in severe pain but not in mild to moderate pain.
4. only followed 4 weeks out and no determination it prevented surgery.
5. of note, these were ESI (not TF)

Eur Rad 27
1. not a blinded or randomized study. just sequential patients.
2. there was significant decrease in NRS and improved patient global impression of change scale with particulates at 1 week and 1 month
3. no long term data included otherwise
4. CT guided epidurals.

Reg Anesth
1. this was a dose ranging study. it was an RCT. but no placebo, and no kenalog or depo. only dex. shows no real difference in dosage.

you cant say kenalog would have been so much better, if no kenalog (or any particulate steroid) was used in the study.


in summary:
1. 2 of the studies suggested that 1 month out the particulate steroid was better.

2. 3 of the studies were low level evidence (Level 3). the other study did not involve particulates

3. there was no long term efficacy of any of the studies, nor any evidence suggesting changes in long term treatment or avoidance of surgery.

4. of note, one of the articles specifically pointed out that the difference could very likely be due to systemic effects from steroid and not the specific steroid itself (Eur Rad 27)

5. no study compared depo to kenalog.





in full disclosure i still use depo particulate steroid for ESI, and only dex for TF.

i see nothing to suggest that using an FDA black box labelled drug (kenalog) is superior or indicated over drugs without such a black box warning (depo), but thats me.
Click to expand...
Damn, can I come to you as a patient? Still reviewing the literature years after training. That's the way it should be.

Where are you getting depo from? Henry Schein tells me there is none available.
 
Ducttape said:
Cureus -
1. retrospective study so not high level of evidence
2. only 1 doctor did the injections.
3. the "tested" individuals were 1/3rd of the total number of injected patients, as these were the ones that did not get significant response.
4. this was not a study that compared dex to any other medication. it was a retrospective study that used triamcinolone for the second injection in the 1/3 of patients who had failed the first.

Eur Rad 2019
1. observational retrospective study
2. did compare dex to triamcinolone
3. found benefit of triamcinolone over dex in severe pain but not in mild to moderate pain.
4. only followed 4 weeks out and no determination it prevented surgery.
5. of note, these were ESI (not TF)

Eur Rad 27
1. not a blinded or randomized study. just sequential patients.
2. there was significant decrease in NRS and improved patient global impression of change scale with particulates at 1 week and 1 month
3. no long term data included otherwise
4. CT guided epidurals.

Reg Anesth
1. this was a dose ranging study. it was an RCT. but no placebo, and no kenalog or depo. only dex. shows no real difference in dosage.

you cant say kenalog would have been so much better, if no kenalog (or any particulate steroid) was used in the study.


in summary:
1. 2 of the studies suggested that 1 month out the particulate steroid was better.

2. 3 of the studies were low level evidence (Level 3). the other study did not involve particulates

3. there was no long term efficacy of any of the studies, nor any evidence suggesting changes in long term treatment or avoidance of surgery.

4. of note, one of the articles specifically pointed out that the difference could very likely be due to systemic effects from steroid and not the specific steroid itself (Eur Rad 27)

5. no study compared depo to kenalog.





in full disclosure i still use depo particulate steroid for ESI, and only dex for TF.

i see nothing to suggest that using an FDA black box labelled drug (kenalog) is superior or indicated over drugs without such a black box warning (depo), but thats me.
Click to expand...
The cureus study is notable because it was the same patients getting different preps and that's far better data than comparing the responses across multiple people with varying degrees of findings. A third of the people failed dex, which is huge. Soon they won't be able to have a repeat injection for a month if they have Medicare and related insurances. You're set up to fail. Far more likely to have treatment failure with dex than catastrophic event with triamcinolone. Majority had better response to particulate. Lets not claim it was the initial dex doing something when its long gone.
 
no, the cureus was 1 doctor who did a TF with dex and when that didnt work, he offered a TF with kenalog.

was it the kenalog alone? what influence in that case did the prior dex injection have? would a kenalog injection as the first injection had the same success? as a second injection, it seemed to be helpful...

or the fact that he got better with the second go around?

or was it the combination of 2 doses of steroids that made it better?



at best, you might be able to say that there is the suggestion that using kenalog for patients with severe pain may be better off for 4 weeks, but even that is flimsy data.

your data is really too weak to support much other than that the dose of dex doesnt matter...
 
Exactly. If medicare won't allow repeat injections in the future, I will always go straight to depo for the patients first epidural.

I just walked out of a room that is a perfect example of what all you people are missing by sticking your head in the sand regarding depo vs dex.

I have a very nice female patient in her mid forties, has a physical job. Upper lumbar pain secondary to L2-L3 spondylolisthesis and a broad disc herniation at that level. Very modest degeneration inferior to L2-L3.

I did a bilateral L3-L4 TFESI with dex a couple months ago and she had 80% relief for 5 days and then her pain returned over 3 days back to baseline.

I then did bilateral S1 TFESI with depo, 6ml of volume on each side to reach L2-L3, and she now has 80% sustained relief for 6 weeks, which is today. She can now sleep without pain, and work with only minimal pain. She is so happy as no other pain physician has been able to help her for the past two years, because all those doctors read the studies, and were good little obedient lambs, but didn't try to think outside the box at all.

Depo kicks dex's ass 80% of the time. I understand that no one has yet completed the double blinded, randomized, placebo controlled, prospective clinical trial to conclusively prove it, but the results are obvious if you open your eyes (and try depo).
 
Last edited:
bedrock said:
Exactly. If medicare won't allow repeat injections in the future, I will always go straight to depo for the patients first epidural.

I just walked out of a room that is a perfect example of what all you people are missing by sticking your head in the sand regarding depo vs dex.

I have a very nice female patient in her mid forties, has a physical job. Upper lumbar pain secondary to L2-L3 spondylolisthesis and a broad disc herniation at that level. Very modest degeneration inferior to L2-L3.

I did a bilateral L3-L4 TFESI with dex a couple months ago and she had 80% relief for 5 days and then her pain returned over 3 days back to baseline.

I then did bilateral S1 TFESI with depo, 6ml of volume on each side to reach L2-L3, and she now has 80% sustained relief for 6 weeks, which is today. She can now sleep without pain, and work with only minimal pain. She is so happy as no other pain physician has been able to help her for the past two years, because all those doctors read the studies, and were good little obedient lambs, but didn't try to think outside the box at all.

Depo kicks dex's ass 80% of the time. I understand that no one has yet completed the double blinded, randomized, placebo controlled, prospective clinical trial to conclusively prove it, but the results are obvious if you open your eyes (and try depo).
Click to expand...
My experience is different than yours. My patients experience 8-12 weeks of relief with dex.
 
Ducttape said:
no, the cureus was 1 doctor who did a TF with dex and when that didnt work, he offered a TF with kenalog.

was it the kenalog alone? what influence in that case did the prior dex injection have? would a kenalog injection as the first injection had the same success? as a second injection, it seemed to be helpful...

or the fact that he got better with the second go around?

or was it the combination of 2 doses of steroids that made it better?



at best, you might be able to say that there is the suggestion that using kenalog for patients with severe pain may be better off for 4 weeks, but even that is flimsy data.

your data is really too weak to support much other than that the dose of dex doesnt matter...
Click to expand...
Exactly. One doctor, the same patients, and the only difference was the preparation. This methodology is eliminating all of the possible confounding variables. This data is the more pure than the studies you consider the gold standard IMO.

The patients getting the second injection had no benefit from the initial procedure so you cannot reasonably consider the effect of the initial injection playing a role--the drug is gone at two weeks and the symptoms were significant. Maybe the doctor's skills got better the second time? That's being childish, to put it politely.

I decided 15 years ago to have both in my TFs: 1cc triamcinolone, 2.5cc dex, 0.5cc 0.25% bupi. It's worked well for me all this time and I see no reason to change. I would like to see the second study leading with particulate but it likely cannot happen with the published data that doesn't fit what I see in my office at all.

bedrock said:
Exactly. If medicare won't allow repeat injections in the future, I will always go straight to depo for the patients first epidural.

I just walked out of a room that is a perfect example of what all you people are missing by sticking your head in the sand regarding depo vs dex.

I have a very nice female patient in her mid forties, has a physical job. Upper lumbar pain secondary to L2-L3 spondylolisthesis and a broad disc herniation at that level. Very modest degeneration inferior to L2-L3.

I did a bilateral L3-L4 TFESI with dex a couple months ago and she had 80% relief for 5 days and then her pain returned over 3 days back to baseline.

I then did bilateral S1 TFESI with depo, 6ml of volume on each side to reach L2-L3, and she now has 80% sustained relief for 6 weeks, which is today. She can now sleep without pain, and work with only minimal pain. She is so happy as no other pain physician has been able to help her for the past two years, because all those doctors read the studies, and were good little obedient lambs, but didn't try to think outside the box at all.

Depo kicks dex's ass 80% of the time. I understand that no one has yet completed the double blinded, randomized, placebo controlled, prospective clinical trial to conclusively prove it, but the results are obvious if you open your eyes (and try depo).
Click to expand...
I see this often enough and have commented on this before. When people have had ESIs that haven't worked, the records show dex was used. Add a depo prep and the results improve.

Are we being reasonable investigators if we just "follow the data" and disregard what we see as well? What some people call anecdotes I call data points.
 
you ignore the point.

the confounding factor is the first injection. you cannot compare the results of the second injection because the patient already had one.

simplistically, he already "prepped" the location and irrigated out the area with the first procedure. from this standpoint at minimum, devoid of all steroid response, you cannot consider the effect of the first injection as being completely gone.

"You cant go back and change the beginning, but you can start where you are and change the ending." C.S. Lewis.

that point aside, it is retrospective data culled from old charts.
pmrmd said:
Are we being reasonable investigators if we just "follow the data" and disregard what we see as well? What some people call anecdotes I call data points.
Click to expand...
"Anecdote generate questions, not answers." Steven Novella.

"The plural of anecdotes is not data." Bob Goldacre.



again, we are talking interlaminar epidural steroids. please do not confound with discussion by telling us what you use for your TF. there is a different reason why to not start with particulate steroids in TF. (fwiw, you use roughly 5x the amount of steroids i do, so i sure as heck hope - from the standpoint of their adrenal glands - they work)
 
Ducttape said:
you ignore the point.

the confounding factor is the first injection. you cannot compare the results of the second injection because the patient already had one.

simplistically, he already "prepped" the location and irrigated out the area with the first procedure. from this standpoint at minimum, devoid of all steroid response, you cannot consider the effect of the first injection as being completely gone.

"You cant go back and change the beginning, but you can start where you are and change the ending." C.S. Lewis.

that point aside, it is retrospective data culled from old charts.

"Anecdote generate questions, not answers." Steven Novella.

"The plural of anecdotes is not data." Bob Goldacre.



again, we are talking interlaminar epidural steroids. please do not confound with discussion by telling us what you use for your TF. there is a different reason why to not start with particulate steroids in TF. (fwiw, you use roughly 5x the amount of steroids i do, so i sure as heck hope - from the standpoint of their adrenal glands - they work)
Click to expand...
The cureus study that we are discussing is about TFs, so don't confound with your talk of interlaminar epidural steroids.

I'm not ignoring anything. The people were given a second injection if the first injection had no response, meaning the steroid was ineffective and any inflammatory mediators were not irrigated out of the area. If the pain after the first injection is unchanged, well after the dex would have been cleared, perhaps you can give a detailed and proven account of what the steroid/volume is doing when neither are still present. Simplistically--nice touch!--stating that a possible reason the second injection was effective because they had zero response to the first is making a nonsensical claim that you cannot prove.

We all know studies have weaknesses. Following them blindly is not being a scientist at all.
 
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