Duloxetine Useless of OA-related Pain

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the study actually suggests that use of duloxetine in primary care offices did not show clinical benefit compared to usual care.

problems with study - they weeded out a lot of people in the study. out of 5000 possible subjects, they ended up getting only 132

nonsignificant difference in duloxetine group.

noone was blinded to treatment

duloxetine patients were more likely to have surgery but they were also more likely to be referred to surgery.

here is the interesting aspect:

Co-interventions

Patients in the duloxetine group contacted their GP more frequently (51.8% vs 30.8% at 3 months, Table 3) and were more often referred to an orthopaedic surgeon (10.7% vs 3.8% at 3 months).

In the total follow-up time, 5 patients in the duloxetine group had a THR or TKR while none of the patients receiving usual care had a THR or TKR.

Patients treated according to usual care used more NSAIDs (48.1% vs 28.1% at 3 months) and opioids (11.5% vs 3.6% at 3 months), and were more likely to receive a corticosteroid injection (6.0 vs 1.8% at 3 months)
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so usual therapy patients were almost twice as likely to use NSAID, 3 times as likely to get an intraarticular injection and 3 times as likely to get an opioid...
 
I remember the promise of cymbalta when I was a resident. I’m much more jaded now and literally never use it for anything but 3rd tier for neuropathic pain.

Other than neuropathic pain, I can count one hand patients said it made a noticeable difference for any other source of pain.
 
bedrock said:
I remember the promise of cymbalta when I was a resident. I’m much more jaded now and literally never use it for anything but 3rd tier for neuropathic pain.

Other than neuropathic pain, I can count one hand patients said it made a noticeable difference for any other source of pain.
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legit OA pain is not going to respond. I think it’s helpful for neuropathic pain, and very tolerable. Helps for fibro and myofascial pain.
 
dipriMAN said:
legit OA pain is not going to respond. I think it’s helpful for neuropathic pain, and very tolerable. Helps for fibro and myofascial pain.
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DODOCSS said:
NNT is better than most (all) we do
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NNT treat is based on the initial industry studies which have now been discredited which is the point of this thread.
I'm very certain that epidurals for radiculopathy, weight loss/steroid/PRP injections for peripheral joint OA, and RFA for spinal facet OA all have vastly superior NNT than cymbalta in the real (non medicaid) world.

Dipri- agree cymbalta can help decrease pain amplification in fibro/depression patients, but I don't think it does jack $hit for the actual OA pain. These type patients I make recs and refer back to PCP anyway with those recs, or my clinic would be clogged with them.
 
bedrock said:
NNT treat is based on the initial industry studies which have now been discredited which is the point of this thread.
I'm very certain that epidurals for radiculopathy, weight loss/steroid/PRP injections for peripheral joint OA, and RFA for spinal facet OA all have vastly superior NNT than cymbalta in the real (non medicaid) world.

Dipri- agree cymbalta can help decrease pain amplification in fibro/depression patients, but I don't think it does jack $hit for the actual OA pain. These type patients I make recs and refer back to PCP anyway with those recs, or my clinic would be clogged with them.
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Indeed, I would argue that it’s such a low risk medicine it’s still worth a try. Certainly lower risk than opioids and NSAIDs, what else do we have when people don’t want an injection or ablation or PT?
 
dipriMAN said:
Indeed, I would argue that it’s such a low risk medicine it’s still worth a try. Certainly lower risk than opioids and NSAIDs, what else do we have when people don’t want an injection or ablation or PT?
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Tramadol.

But also if they don’t want to do anything else I point to my business card which says bedrock, MD, Interventional Pain, not bedrock, PCP, or bedrock, psychiatry, and I tell them if they don’t want to do anything I recommend then there is no reason for them to return to my office.

I don’t say this to patients who want to focus on conservative treatments first such a good PT program, because as PMR/Pain, I’m well equipped to write a good PT script and send them to right PT for their issue. But I also don’t want to see them again after the initial PT follow up unless they are ready for a procedure.

For people who truly don’t want to do anything, I don’t even write tramadol, lyrica or anything else. Those meds are an adjunct, to weight loss , pain relief until procedure authed, or for the residual 20% of pain after you resolved the first 80%, so they don’t have an unnecessary surgery.

For people who truly don’t want to do anything to actually get better , I don’t do anything except refer back to Pcp, (or to psych/pain psych if they will accept it). I don’t have time to waste on slugs.
 
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tramadol is an opioid legally, and patients can become dependent or addicted. imo and those of the DEA, tramadol does not appear to be a routine drug to use.

===
as a pain physician and not an interventionalist exclusively, i utilize interventions are one aspect of pain management, but not the only one. medications - even if they there is the potential they may not work, just like injections - are one of those aspects to consider.

===
the best i can find for NNT for injections are that epidural injections and TF injections for short term pain have an NNT of 7 based on this consensus statement drawn up by neurology.


The NNT (a measure of clinical efficacy) for short-term pain reduction in 14 radiculopathy is 7, meaning that if 7 patients are treated 1 additional patient will have any degree 15 of pain relief. The CI for the NNT was 4-15, meaning that between 4 and 15 patients might have 16 to be treated for 1 additional patient to derive any pain relief. In radiculopathy, for short-term 17 disability, the NNT is 10 (95% CI, 6 to 32). The small effect size and the modest clinical efficacy 18 for short-term benefit need to be considered when using ESIs for lumbosacral radiculopathy.
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this group could not post an NNT for long term disability or long term pain because there was no benefit.

yes, no NNT for chronic radicular pain or spinal stenosis.


the NNT from duloxetine appears to be between 5 and 7 for osteoarthritis.

Duloxetine in the management of chronic musculoskeletal pain - PMC

Chronic musculoskeletal pain is among the most frequent painful complaints that healthcare providers address. The bulk of these complaints are chronic low back pain and chronic osteoarthritis. Osteoarthritis is the most common form of arthritis in ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

it may be 4 to 6 for diabetic neuropathy and for fibromyalgia

Duloxetine: painful diabetic neuropathy and fibromyalgia

Duloxetine: painful diabetic neuropathy and fibromyalgia
www.bandolier.org.uk
 
Ducttape said:
tramadol is an opioid legally, and patients can become dependent or addicted. imo and those of the DEA, tramadol does not appear to be a routine drug to use.

===
as a pain physician and not an interventionalist exclusively, i utilize interventions are one aspect of pain management, but not the only one. medications - even if they there is the potential they may not work, just like injections - are one of those aspects to consider.

===
the best i can find for NNT for injections are that epidural injections and TF injections for short term pain have an NNT of 7 based on this consensus statement drawn up by neurology.



this group could not post an NNT for long term disability or long term pain because there was no benefit.

yes, no NNT for chronic radicular pain or spinal stenosis.


the NNT from duloxetine appears to be between 5 and 7 for osteoarthritis.

Duloxetine in the management of chronic musculoskeletal pain - PMC

Chronic musculoskeletal pain is among the most frequent painful complaints that healthcare providers address. The bulk of these complaints are chronic low back pain and chronic osteoarthritis. Osteoarthritis is the most common form of arthritis in ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

it may be 4 to 6 for diabetic neuropathy and for fibromyalgia

Duloxetine: painful diabetic neuropathy and fibromyalgia

Duloxetine: painful diabetic neuropathy and fibromyalgia
www.bandolier.org.uk
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I know it is possible but I have still not seen a single case of tramadol abuse in 12 years of private practice.

Its not always about the financial component of injections, it is also a matter of patients actively participating in their care. If a patient literally doesn't want to do anything, they will never get better, no matter what pill you give them, so I now choose not to go down that path.

NNT for cymbalta is a total lie as those studies have been shown to be false by clinical experience. I would expect the NNT for cymbalta to be closer to 100.
 
i have seen at least 5 patients that were truly addicted to tramadol. 1 that i took over from the prior docs, 4 that i saw as referrals.

i have also had 3 other patients that have had subjective severe withdrawal symptoms with tapering off tramadol.

the 4 i saw as referrals were discounted by the primaries because they were told "tramadol abuse doesnt exist".

but when a patient is taking 15 tramadols a day to get a buzzy feeling (which is probably serotonin related more than anything else...), then there is an issue.

---
your last statement is specious.

please post data to support that contention.
 
I don't practice in pain, only in psychiatry. I have seen more tramadol abuse and addiction than I care to count. I have worked on inpatient medically assisted withdrawal units where, on some days, more than half of the patients only ever used tramadol. Plenty of people take too much of it, and the risks of excessive use are potentially worse than the risks of excess use of other "cleaner" opioids. I don't have the data to make a real comparison, so I won't. Same thing with codeine.

I've seen plenty of abuse of just about all medications, though. Tons of people taking 600+ mg of Benadryl for a buzz. People taking several grams a day of loperamide, megadoses of Nucynta, and of course Neurontin. People even snort Elavil if give a chance.

Interestingly but also anecdotally, none of these were started by pain management physicians, but instead by PCPs, specialist NPs, or other providers. Sure, many of these patients went to pain management at some point, but they tended to stop going to pain management with various rationalizations.

As a psychiatrist, I've been pleasantly surprised by the patients whose pain improves with Cymbalta. Usually there's a strong psychological component. Frankly, they tend to do better when I explain that it has an FDA indication outside of psychiatry. And most prominently when they tell me they carry a fibro diagnosis or have a history of heroin use and tell me they want to stay away from opioids for their sciatica (which I don't diagnose, but they tell me they have and I don't argue). Probably see the same level of benefit if not a little more with Cymbalta than with a TENS unit, which I never prescribe but they ask me about and I don't tell them one way or the other.
 
It's the person and not the drug. Hmm, sounds like SOS or juice the vig.

Tramadol has abuse potential. I've seen one. How many does it take to get resp suppression? More likely to die from SS. I believe literature suggests only 5% of Ultram overdoses involve resp suppression. Wonder if part of polysubstance OD.
 
lobelsteve said:
It's the person and not the drug. Hmm, sounds like SOS or juice the vig.

Tramadol has abuse potential. I've seen one.
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Agree with this. Particularly it’s the person not the drug. Idiots will take anything to feel like something other than themselves, which is addiction 101. That doesn't mean tramadol is particularly addictive.

As mentioned above I don't write any kind of prescription even NSAIDS or gabapentin to slugs or patients with mostly mental issues, not anatomic issues, as I don't want to establish a relationship and I don't want to see them again.
So in the resulting non psych cohort you can write tramadol to anyone. Duct sees lots of medicaid which is psych by another name over half of the time, and the psychiatrist poster obviously sees major head cases. Apples and oranges to my population which is medicare and hardworking patients on commercial insurance.
 
bedrock said:
Agree with this. Particularly it’s the person not the drug. Idiots will take anything to feel like something other than themselves, which is addiction 101. That doesn't mean tramadol is particularly addictive.

As mentioned above I don't write any kind of prescription even NSAIDS or gabapentin to slugs or patients with mostly mental issues, not anatomic issues, as I don't want to establish a relationship and I don't want to see them again.
So in the resulting non psych cohort you can write tramadol to anyone. Duct sees lots of medicaid which is psych by another name over half of the time, and the psychiatrist poster obviously sees major head cases. Apples and oranges to my population which is medicare and hardworking patients on commercial insurance.
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en.wikipedia.org

Benadryl challenge - Wikipedia

en.wikipedia.org en.wikipedia.org
 
Apparently my parents’ friend invented duloxetine and he’s enjoying a fantastic retirement right now.
 
Did you know that one of the best medications in preclinical models of arthritis is gabapentin? Unfortunately, most people aren't rodents.

I ask patients about whether their pain is spontaneous/continuous or mechanical/inducible. Duloxetine/Gabapentin help more the former pain pattern and less the latter. The spontaneous/continuous/can't get comfortable/can't stop pain is more neuropathic than nociceptive.
 
I do a good amount of gabapentin and cymbalta combo prescriptiions. Seems to work fairly well with minimal side effects. No slugs in my practice. I think the polypharmacy is synergistic and typically need to get cymbalta to 60mg. Certainly not a cure all but covers myofascial and neuropathic pain decently.
 
Ligament said:
I do a good amount of gabapentin and cymbalta combo prescriptiions. Seems to work fairly well with minimal side effects. No slugs in my practice. I think the polypharmacy is synergistic and typically need to get cymbalta to 60mg. Certainly not a cure all but covers myofascial and neuropathic pain decently.
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good idea. Do you start them separately to assess side effects from each individual drug? Which do you start with first if you are assuming you'll end up on both?

As it seems 1/3 of the doctor going US population is on an SSRI, how does that influence you?
 
bedrock said:
good idea. Do you start them separately to assess side effects from each individual drug? Which do you start with first if you are assuming you'll end up on both?

As it seems 1/3 of the doctor going US population is on an SSRI, how does that influence you?
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Hey buddy; I don't start them separately as it would take too long to follow them and titrate up, but there is nothing wrong if you choose to do that. I start gabapentin at 600-900 MG PO TID and Cymbalta 30mg PO QAM x 2 weeks increase to 60mg QAM thereafter. Re-eval in a month or two. Tell them it is going to take a month to see benefit.

If they are on an SSRI or TCA, either I have time stop for 1-2 weeks if it is some bull**** med like a tricicylic that is snowing them, or have them ask their psychiatrist to switch them to cymbalta and they psychiatrist can handle it and also monitor the psych effects. A good amount of the folks I see are on a TCA for pain and cannot tolerate it.

As I write this is sound complicated but really its not.
 
Ligament said:
Hey buddy; I don't start them separately as it would take too long to follow them and titrate up, but there is nothing wrong if you choose to do that. I start gabapentin at 600-900 MG PO TID and Cymbalta 30mg PO QAM x 2 weeks increase to 60mg QAM thereafter. Re-eval in a month or two. Tell them it is going to take a month to see benefit.

If they are on an SSRI or TCA, either I have time stop for 1-2 weeks if it is some bull**** med like a tricicylic that is snowing them, or have them ask their psychiatrist to switch them to cymbalta and they psychiatrist can handle it and also monitor the psych effects. A good amount of the folks I see are on a TCA for pain and cannot tolerate it.

As I write this is sound complicated but really its not.
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That is a bit aggressive for me unless we are talking CRPS type neuropathic pain. You start some patients on gaba 900 TID?

I know you are trying to cancel out side effects from each drug, but most non obese patients starting gabapentin can barely tolerate 300 TID and most patients starting cymbalta can barely tolerate 30mg.

Maybe I'm being a wimp about this, but I guess I would feel more comfortable starting Cymbalta 30mg and gabapentin 300 TID for a month, and recheck for medication tolerance after that.
 
bedrock said:
That is a bit aggressive for me unless we are talking CRPS type neuropathic pain. You start some patients on gaba 900 TID?

I know you are trying to cancel out side effects from each drug, but most non obese patients starting gabapentin can barely tolerate 300 TID and most patients starting cymbalta can barely tolerate 30mg.

Maybe I'm being a wimp about this, but I guess I would feel more comfortable starting Cymbalta 30mg and gabapentin 300 TID for a month, and recheck for medication tolerance after that.
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I am aggressive with cymalta, I get up to 60 mg fairly quickly. I always start gaba 300 and titrate to TID over weeks. Even then many people get side effects.
 
bedrock said:
That is a bit aggressive for me unless we are talking CRPS type neuropathic pain. You start some patients on gaba 900 TID?

I know you are trying to cancel out side effects from each drug, but most non obese patients starting gabapentin can barely tolerate 300 TID and most patients starting cymbalta can barely tolerate 30mg.

Maybe I'm being a wimp about this, but I guess I would feel more comfortable starting Cymbalta 30mg and gabapentin 300 TID for a month, and recheck for medication tolerance after that.
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I support you moving at whatever pace works for you and your patients. In my area, I most commonly see people state "I tried Gabapentin and it did nothing for me." The dose they were on is typically 300 TID at the max...so I've been writing a 600-900TID dose for years. If 600 is too much they simply take less. However they get a therapeautic dose quickly this way, no more 3-6 months of titration, or giving up before reaching a decent dose. Gabapentin is very safe so I feel fine with this dose.

I don't think you are being a wimp, and I think your plan of 300TID Gabapentin and 30mg Cymbalta is totally reasonable.
 
Cymbalta: 30mg qd x 7d then 60mg qd
Gabapentin titration: 300 qhs x3d, 300 bid x3d, 300 tid x3d, 300/300/600, 300/600/600, 600/600/600. Each step is 3 days. Titration on my short list in EHR so 1 click and it prints.

Effective dose range of gabapentin is 1800-2700mg divided bid or tid.
 
lobelsteve said:
Cymbalta: 30mg qd x 7d then 60mg qd
Gabapentin titration: 300 qhs x3d, 300 bid x3d, 300 tid x3d, 300/300/600, 300/600/600, 600/600/600. Each step is 3 days. Titration on my short list in EHR so 1 click and it prints.

Effective dose range of gabapentin is 1800-2700mg divided bid or tid.
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Exactly how I do it
 
Do you increase past 600 TID if they haven’t noticed any improvement? I always thought if no improvement at 1800 daily very unlikely to notice improvement higher, but if some improvement at 1800 then it’s reasonable to try higher, as tolerated.
 
MD87 said:
Do you increase past 600 TID if they haven’t noticed any improvement? I always thought if no improvement at 1800 daily very unlikely to notice improvement higher, but if some improvement at 1800 then it’s reasonable to try higher, as tolerated.
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Would push to 900 tid and if no better, dc.
 
MD87 said:
Do you increase past 600 TID if they haven’t noticed any improvement? I always thought if no improvement at 1800 daily very unlikely to notice improvement higher, but if some improvement at 1800 then it’s reasonable to try higher, as tolerated.
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I will only increase to 300 TID. I read somewhere that there is minimal increased efficacy above that dose.
 
Ferrismonk said:
I will only increase to 300 TID. I read somewhere that there is minimal increased efficacy above that dose.
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www.pharmacytimes.com

Appropriate Gabapentin Dosing for Neuropathic Pain

The established therapeutic dosing for gabapentin in neuropathic pain is 1800-3600 mg/day in 3 divided doses in patients with normal renal function.
www.pharmacytimes.com www.pharmacytimes.com


Try google. Article I quote for my data was from 2002-03. This is updated.
 
The difference in 1800 and 3600 is side effects, not efficacy.

I think 1200 to 1800 is worthwhile.

Vast majority of my gabapentin is 100mg TID.
 
MitchLevi said:
The difference in 1800 and 3600 is side effects, not efficacy.

I think 1200 to 1800 is worthwhile.

Vast majority of my gabapentin is 100mg TID.
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If they do not have side effects but report it does not work, consider getting in range. It is not a failure until they have side effects that don't resolve in 3-4 days or dose reached 2700mg.
 
That’s a very black and white way to treat gabapentin. I have a lot of patients who do well with asymmetrical dosing, like 400mg qAM and 800mg qHS, no post lunch drowsiness and sleep like a baby
 
ive been getting away from gabapentin lately. and i dont use lyrica much if at all.

1. there is a potential addiction concern with gabapentin
2. most studies show no benefit from chronic back pain, low benefit from radicular pain
3. side effects, and the fact that most patients get started on this medication by their PCP already
4. very few get up to 1800 mg daily due to side effects.

for cymbalta, 30 mg daily for 2 weeks, then 60 mg daily. may will go up to 80 (2 40 mg pills a day).

if already on SSRI, if primary prescriber is PCP and not psych, then will transition if primary prescriber okays. easy to transition - cut the other SSRI in 1/2 for two days, then start full dose cymbalta. i never take people completely off.
 
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