Help with tough case.

[gator2886]

---

Members do not see this ad.

70 year old female with bad spondy. Predominant leg symptoms. Too osteopenic for TLF. Moderate dementia and depression.
Lyrica and Gabapentin worsen mental function to the point she can't use. SCS trial failed due to dementia limiting proper management of device. On SSRI for depression (sertraline.) I added tramadol with the hopes it would not worsen mental function and tapered off sertraline. Patient now having crying spells and worsening depression. It was thought if the pain improved the depression would as well. I have added back the sertraline but need something for neuropathic pain. I was thinking of Sevella off label for the depression and add back the tramadol? Just add back tramadol and counsel regarding serotonin syndrome?? Thoughts?

 

[lobelsteve]

Add Butrans 5 µg and send her off to the nursing home. At least you got paid to do a trial on a demented patient.

 

[SSdoc33]

Add Butrans 5 µg and send her off to the nursing home. At least you got paid to do a trial on a demented patient.

he(she) never said he did the trial. somebody who is doing so much medication management may not be the actual SCS trialer.

also no mention of a TFESI?

 

[Baron Samedi]

The effect of mirtazapine in patients with chronic pain and concomitant depression - PubMed

Despite the limitations of an open observational study, our findings suggest that mirtazapine is a safe and well-tolerated drug for use in daily clinical practice. It still remains unclear whether the reduction of pain, the enhancement of the depressed mood or the combination of both effects led...

pubmed.ncbi.nlm.nih.gov

 

[SommeRiver]

Agree Remeron.

Other injxns possible? RFA or epidural?

Forget about serotonin syndrome.

 

[BobBarker]

Spinoplasty and then minuteman.
Alternatively, try a back brace.

 

[Timeoutofmind]

70 year old female with bad spondy. Predominant leg symptoms. Too osteopenic for TLF. Moderate dementia and depression.
Lyrica and Gabapentin worsen mental function to the point she can't use. SCS trial failed due to dementia limiting proper management of device. On SSRI for depression (sertraline.) I added tramadol with the hopes it would not worsen mental function and tapered off sertraline. Patient now having crying spells and worsening depression. It was thought if the pain improved the depression would as well. I have added back the sertraline but need something for neuropathic pain. I was thinking of Sevella off label for the depression and add back the tramadol? Just add back tramadol and counsel regarding serotonin syndrome?? Thoughts?

Could try Keppra

Or topamax

 

[Baron Samedi]

Also any reason to jump to savella and not just use duloxetine? I probably wouldn't have touched her sertraline but now that she's off of it might as well try something with potential pain benefit.

How about aqua therapy?

 

[Ducttape]

ya. depression worse off sertraline. tramadol not enough of an SSRI for depression.

2 options:
1. stop sertraline and tramadol, start Cymbalta, try butrans patch.
2. stop tramadol, continue sertraline, start nucynta ER.

 

[sloh]

Why gamble with the unpredictability of Tramadol? Just use Norco. The idea that Tramadol is less dangerous than Norco has been debunked.

 

[willabeast]

I would not give any medication that could affect CNS to someone with dementia.

 

[sloh]

I would not give any medication that could affect CNS to someone with dementia.

Exactly, this patient probably shouldn't be on norco or tramadol.

 

[mja75]

I don't recommend opioids for patients with recurring AMS however if you absolutely must, Butrans patch is an excellent option. If her leg symptoms are consistent with NC and she has neuroforaminal stenosis, interspinous decompression like Vertiflex might help. It may raise some eyebrows to perform this procedure on someone with dementia, however, due to questions of informed consent.

 

[Ferrismonk]

Wheelchair?

If you want to go palliative, go Butrans.

 

[gator2886]

I have already tried epidurals

 

[gator2886]

Also any reason to jump to savella and not just use duloxetine? I probably wouldn't have touched her sertraline but now that she's off of it might as well try something with potential pain benefit.

How about aqua therapy?

tried aqua therapy. Savella has far less 5ht properties.

 

[gator2886]

The patient has excellent family support. Her dementia has worsened since I began seeing her 6 mo ago

 

[gator2886]

Agree Remeron.

Other injxns possible? RFA or epidural?

Forget about serotonin syndrome.

thanks, I may try this approach. Patient is overweight so weight gain is an issue

 

[gator2886]

Spinoplasty and then minuteman.
Alternatively, try a back brace.

using back brace already

 

[gator2886]

ya. depression worse off sertraline. tramadol not enough of an SSRI for depression.

2 options:
1. stop sertraline and tramadol, start Cymbalta, try butrans patch.
2. stop tramadol, continue sertraline, start nucynta ER.

So, Tapentadol may be a good option. Low concern for 5HT syndrome with that and sertraline?

 

[Ducttape]

her depression is a primary problem.

but this is an somewhat elderly patient who has moderate dementia. I don't think just "avoiding medications that affect mental status" will help in what sounds more like a palliative care situation in a patient with moderate dementia than a healthy 70 year old. she sounds old, relatively speaking.


there is still the concern for serotonin syndrome, so lowest dose possible is still the best treatment plan. and yes, if you wanted to, you could use as needed Norco, though I would probably switch the sertraline to Cymbalta just to see if the SNRI has some pain benefits.

 

[SommeRiver]

thanks, I may try this approach. Patient is overweight so weight gain is an issue

Weight gain isn't an issue IMO, but that's my opinion.

Depression is the primary problem.

 

[painfree23]

Why gamble with the unpredictability of Tramadol? Just use Norco. The idea that Tramadol is less dangerous than Norco has been debunked.

Wat?

 

[sloh]

Wat?

Tox & Hound: Tramadont

by David Juurlink Let’s get this out of the way, shall we? Tramadont. Not a word, you say? Look it up. The exhortation to avoid

emcrit.org

"The conversion of tramadol to ODT happens in the liver – obviously. That’s where one of the cytochrome P450 enzymes (CYP2D6) removes a methyl group, magically converting an SNRI (tramadol) into an opioid (ODT).

And this is where tramadol starts falling apart.

Why? Because CYP2D6 activity varies tremendously among individuals and across ethnic groups. Somewhere between 3-10% of Caucasians are “poor metabolizers”, meaning they have no functional CYP2D6. Most exhibit an ‘intermediate” or “extensive” (that is, normal) metabolizer phenotype, while some (2-10% or more, depending on the country of origin) are “ultrarapid metabolizers”.

When you give a patient tramadol, you have no idea whether you’re giving an SNRI or an SNRI-opioid combo. In other words, prescribing tramadol is like prescribing venlafaxine and morphine in an unknown ratio. And seriously, why do that?"

 

[lobelsteve]

Tox & Hound: Tramadont

by David Juurlink Let’s get this out of the way, shall we? Tramadont. Not a word, you say? Look it up. The exhortation to avoid

emcrit.org

"The conversion of tramadol to ODT happens in the liver – obviously. That’s where one of the cytochrome P450 enzymes (CYP2D6) removes a methyl group, magically converting an SNRI (tramadol) into an opioid (ODT).

And this is where tramadol starts falling apart.

Why? Because CYP2D6 activity varies tremendously among individuals and across ethnic groups. Somewhere between 3-10% of Caucasians are “poor metabolizers”, meaning they have no functional CYP2D6. Most exhibit an ‘intermediate” or “extensive” (that is, normal) metabolizer phenotype, while some (2-10% or more, depending on the country of origin) are “ultrarapid metabolizers”.

When you give a patient tramadol, you have no idea whether you’re giving an SNRI or an SNRI-opioid combo. In other words, prescribing tramadol is like prescribing venlafaxine and morphine in an unknown ratio. And seriously, why do that?"

Mu binding never even approaches codeine even at 300mg per day. Safety profile much more favorable than nsaids.

 

[sloh]

Mu binding never even approaches codeine even at 300mg per day. Safety profile much more favorable than nsaids.

With tramadol, you're still giving an unknown ratio of SNRI or SNRI-opioid combo. If you want to give an opioid, then give an opioid. If you want to give an SNRI, then give an SNRI.

 

[SommeRiver]

With tramadol, you're still giving an unknown ratio of SNRI or SNRI-opioid combo. If you want to give an opioid, then give an opioid. If you want to give an SNRI, then give an SNRI.

This sounds like Step 3 stuff that doesn't mean anything in real life.

 

[lobelsteve]

With tramadol, you're still giving an unknown ratio of SNRI or SNRI-opioid combo. If you want to give an opioid, then give an opioid. If you want to give an SNRI, then give an SNRI.

Agrred. But if I can get SNRI and mild opiate action, then it is a single drug doing the work of two.

 

[sloh]

This sounds like Step 3 stuff that doesn't mean anything in real life.

In what way does this not mean anything in real life? The only argument I can see in favor of Tramadol is because a physician wants the effects of an opioid and SNRI but doesn't think the patient can or is willing to take two medications.

 

[ED50]

Agree with stop sertraline, start duloxetine and can add +/- butrans patch. Makes sense to me

 

[SommeRiver]

In what way does this not mean anything in real life? The only argument I can see in favor of Tramadol is because a physician wants the effects of an opioid and SNRI but doesn't think the patient can or is willing to take two medications.

I use tramadol all the time and it is better tolerated than the majority of other meds.

 

[BobBarker]

Can you post images of the spondy? Do you have a flex and ext film available?

 

[Agast]

Wheelchair?

If you want to go palliative, go Butrans.

I prefer Fentanyl patch if truly palliative. I think it’s better for pain that needed a surgical procedure.

 

[Espn123]

Add Butrans 5 µg and send her off to the nursing home. At least you got paid to do a trial on a demented patient.

Can you educate me on your butrans practice? In a nutshell? Seems like a good thing to add, I’ve dabbled but I think I could do a lot more

 

[lobelsteve]

Can you educate me on your butrans practice? In a nutshell? Seems like a good thing to add, I’ve dabbled but I think I could do a lot more

Start at 5 if naive. Qweek.
start at 10 for all others qweek.
Double if not getting results.

 

[gator2886]

This patient is not palliative.

 

[gator2886]

Agree with stop sertraline, start duloxetine and can add +/- butrans patch. Makes sense to me

So ED50 help me out here. Cymbalta you think would cover the depression?

 

[Ferrismonk]

So ED50 help me out here. Cymbalta you think would cover the depression?

That's it's primary indication...

 

[avalon10]

Duragesic patch and that's it

 

[Baron Samedi]

This patient is not palliative.

Dementia is a terminal diagnosis. If she's only 70 and already has moderate dementia as measured by a validated scale, she is palliative.

Characterization of Dementia and Alzheimer’s Disease in an Older Population: Updated Incidence and Life Expectancy With and Without Dementia - PMC

Objectives. We estimated dementia incidence rates, life expectancies with and without dementia, and percentage of total life expectancy without dementia. Methods. We studied 3605 members of Group Health (Seattle, WA) aged 65 years or older who did ...

www.ncbi.nlm.nih.gov

 

[Espn123]

Start at 5 if naive. Qweek.
start at 10 for all others qweek.
Double if not getting results.

Thank you, any experience with belbuca?

 

[lobelsteve]

Thank you, any experience with belbuca?

Lots. Used when Butrans not preferred or when patch falls off at day 4.

 

[deleted875186]

70 year old female with bad spondy. Predominant leg symptoms. Too osteopenic for TLF. Moderate dementia and depression.
Lyrica and Gabapentin worsen mental function to the point she can't use. SCS trial failed due to dementia limiting proper management of device. On SSRI for depression (sertraline.) I added tramadol with the hopes it would not worsen mental function and tapered off sertraline. Patient now having crying spells and worsening depression. It was thought if the pain improved the depression would as well. I have added back the sertraline but need something for neuropathic pain. I was thinking of Sevella off label for the depression and add back the tramadol? Just add back tramadol and counsel regarding serotonin syndrome?? Thoughts?

I personally think this is a candidate for chronic opioid therapy. No mention in your post if an opioid other than tramadol was tried and was tolerated. I honestly think gaba and Lyrica have just as much if not more effect on mental status than some opioids.

why not try a weak opioid as suggested above and see what happens. Buprenorphine or Vicodin, put back on the sertraline if it was working for her.

 

[BobBarker]

Agreed. Gabapentinoids have much more effect on mental status in her elderly than opioids. Norco 5mg BID might be all she needs for a couple years until her mind leaves her.

 

[ED50]

So ED50 help me out here. Cymbalta you think would cover the depression?

As others said yes, I've had no problem with patient's becoming more depressed when switching from an SSRI to the SNRI class. Occasionally you will get a slam dunk which treats the depression and really helps with their chronic pain.

 

[deleted875186]

Also, I too am afraid of serotonin syndrome with tramadol. Every case I’ve heard of has involved tramadol mixed with other meds.

 

[SommeRiver]

Also, I too am afraid of serotonin syndrome with tramadol. Every case I’ve heard of has involved tramadol mixed with other meds.

Never seen it.

I have A LOT of ppl on tramadol.

I will continue to Rx it as my first line drug unless there is a specific reason not to Rx it, and being on an SSRI or SNRI ain't one.

 

[deleted875186]

Never seen it.

I have A LOT of ppl on tramadol.

I will continue to Rx it as my first line drug unless there is a specific reason not to Rx it, and being on an SSRI or SNRI ain't one.

Wonder if anyone else has seen it with SSRIs and tramadol?

 

[gazzer]

Spinoplasty and then minuteman.
Alternatively, try a back brace.

Can you please elaborate a bit more on your indications for minuteman? Degree of spondylolisthesis, unstable vs stable, concomitant central canal, lateral recess, foraminal stenosis? Does it provide decompression in cases with stenosis? Just trying to learn a bit more. Can't find much info on their website. Thanks.

 

[BobBarker]

It does provide indirect decompression and can be done in cases with instability. I have been doing it in patients with grade 1 spondy, stenosis, and very poor surgical candidates for a traditional surgery