How common is the use of Adjuvant analgesics in Podiatry

[cool_vkb]

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I came across an article today regarding pain management where it was discussing the use of Adjuvant Analgesics in the managing Neuroma pain.

According to the article , The term ‘‘adjuvant analgesics'' traditionally refers to a large and diverse group of drugs, most of which have demonstrated analgesic effects in specific circumstances but do not have Food and Drug Administration (FDA)- approved labeling for pain.

This again goes back to the age old debate of Phamacists acting as MONITORS and questioning the prescription. Does anybody knows more about this. i remember Diabeticfootdr once giving an example of such situation but i dnt remember the details.

An example for my question will be, according to the article one can prescribe Tricyclic Antidepressants (Amitryptiline for eg) or Anticonvulsants (Gabapentin) for the treatment for neuropathic pain. Now lets say the pharmacist is not updated with the new research or new articles that we read. He may question the prescription thinking how can one use an antidepressant for foot problem. does this happen?

I dont want to lose this thread to interthread wars with pharm people. Prepods and freshmen plzz stay away if you dont hve anything usefull to contribute!

 

[PADPM]

My personal feeling is that the use of these types of drugs for a condition such as a neuroma is a bit of "overkill".

There are a significant number of treatment options available for this relatively benign process. Currently available treatments include, but are not limited to; metatarsal pads/cushions, shoe changes/modifications, orthoses, physical therapy, steroid injections, sclerosing alcohol injections, surgical excision through a dorsal incision, surgical excision through a plantar incision, "decompression" of the transverse metatarsal ligament without neuroma excision, cryosurgery, radiofrequency surgery, and NSAID's. I may have left out one two.

Medications such as Neurontin, Lyrica, Cymbalta, and/or the tricyclic anti-depressants also have some very significant potential systemic side effects, and can interact with a lot of other medications. Although these meds can be useful for peripheral neuropathy and are also used to augment pain control, I personally do not believe their use is indicated for neuromas.

Naturally, there are always exceptions, but I'm speaking in general.

 

[XCdude]

My personal feeling is that the use of these types of drugs for a condition such as a neuroma is a bit of "overkill".

There are a significant number of treatment options available for this relatively benign process. Currently available treatments include, but are not limited to; metatarsal pads/cushions, shoe changes/modifications, orthoses, physical therapy, steroid injections, sclerosing alcohol injections, surgical excision through a dorsal incision, surgical excision through a plantar incision, "decompression" of the transverse metatarsal ligament without neuroma excision, cryosurgery, radiofrequency surgery, and NSAID's. I may have left out one two.

Medications such as Neurontin, Lyrica, Cymbalta, and/or the tricyclic anti-depressants also have some very significant potential systemic side effects, and can interact with a lot of other medications. Although these meds can be useful for peripheral neuropathy and are also used to augment pain control, I personally do not believe their use is indicated for neuromas.

Naturally, there are always exceptions, but I'm speaking in general.

Neurontin/gabapentin is the gold standard. none of the others have been proven effective at treating neuropathy...

 

[diabeticfootdr]

Neurontin/gabapentin is the gold standard. none of the others have been proven effective at treating neuropathy...

Neurontin is not the gold standard. In fact, it is not even FDA approved for neuropathic pain.

Cymbalta and Lyrica are.

 

[diabeticfootdr]

I came across an article today regarding pain management where it was discussing the use of Adjuvant Analgesics in the managing Neuroma pain.

According to the article , The term ‘‘adjuvant analgesics’’ traditionally refers to a large and diverse group of drugs, most of which have demonstrated analgesic effects in specific circumstances but do not have Food and Drug Administration (FDA)- approved labeling for pain.

This again goes back to the age old debate of Phamacists acting as MONITORS and questioning the prescription. Does anybody knows more about this. i remember Diabeticfootdr once giving an example of such situation but i dnt remember the details.

An example for my question will be, according to the article one can prescribe Tricyclic Antidepressants (Amitryptiline for eg) or Anticonvulsants (Gabapentin) for the treatment for neuropathic pain. Now lets say the pharmacist is not updated with the new research or new articles that we read. He may question the prescription thinking how can one use an antidepressant for foot problem. does this happen?

In your first sentence you wrote "neuroma pain" ... I believe you meant neuropathic pain?

Regarding antidepressants/anticonvulsants for neuropathic pain: They are effective and there is abundant literature confirming this. If you write a valid prescription, a pharmacist can not deny filling it because they are uninformed. So inform them of why you're writing it (not that you have to), and that settles it.

 

[cool_vkb]

iam sorry i meant Neuropathic pain. not neuroma. 🙂


btw, what does it mean by the term "Diagnostic injections for Neuroma".

 

[krabmas]

iam sorry i meant Neuropathic pain. not neuroma. 🙂


btw, what does it mean by the term "Diagnostic injections for Neuroma".

A diagnostic injection for a neuroma is typically injecting only a local anesthetic into the intermetatarsal space (onto the common digital nerve) proximal to the neuroma. If the pain goes away or cannot be elicited w/ palpation any more then the pathology causing the pain is most likely a neuroma.

Then a treatment injection can be given if indicated which consists of steroid or sclerosing alcohol.

The diagnostic injection can be used to diagnose/isolate sinus tarsi pain, ankle pain, STJ pain... Some people do these injections under fluoroscopy as well to make sure of being in the right joint especially in the midfoot.

 

[NatCh]

I came across an article today regarding pain management where it was discussing the use of Adjuvant Analgesics in the managing Neuroma pain.

According to the article , The term ‘‘adjuvant analgesics’’ traditionally refers to a large and diverse group of drugs, most of which have demonstrated analgesic effects in specific circumstances but do not have Food and Drug Administration (FDA)- approved labeling for pain.

This again goes back to the age old debate of Phamacists acting as MONITORS and questioning the prescription. Does anybody knows more about this. i remember Diabeticfootdr once giving an example of such situation but i dnt remember the details.

An example for my question will be, according to the article one can prescribe Tricyclic Antidepressants (Amitryptiline for eg) or Anticonvulsants (Gabapentin) for the treatment for neuropathic pain. Now lets say the pharmacist is not updated with the new research or new articles that we read. He may question the prescription thinking how can one use an antidepressant for foot problem. does this happen?

I dont want to lose this thread to interthread wars with pharm people. Prepods and freshmen plzz stay away if you dont hve anything usefull to contribute!

It is very common to use those meds to treat neuropathic pain, and don't worry, Pharmacists are by-and-large up-to-date with this application as it is nothing new or unusual.

 

[cool_vkb]

A diagnostic injection for a neuroma is typically injecting only a local anesthetic into the intermetatarsal space (onto the common digital nerve) proximal to the neuroma. If the pain goes away or cannot be elicited w/ palpation any more then the pathology causing the pain is most likely a neuroma.

Then a treatment injection can be given if indicated which consists of steroid or sclerosing alcohol.

The diagnostic injection can be used to diagnose/isolate sinus tarsi pain, ankle pain, STJ pain... Some people do these injections under fluoroscopy as well to make sure of being in the right joint especially in the midfoot.

thanks a lot.

when it said "Diagnostic" i was thinking in the lines of a contrast injection like in MRI but i was not sure what we would be seeing in Neuroma with contrast 🙂.

thanks for clearing it. Every day before i go to sleep im reading two articles from the Clinics in Podiatric Medicine and Surgery Journal. its like bedtime stories . hopefully when i go for my first rotation in february all these will come handy.

 

[PADPM]

Neuroma pain and neuropathy pain are a whole different story!!!!!!!!

That's why in my original post I rambled on about why those meds were not appropriate for neuroma pain.

And I just love when a podiatry student comes on this forum such as "XCdude" and tells me, after over 20 years of practice, that gabapentin/Neurontin is the "gold standard" and "none of the others have even been proven to be effective....."

Yet "XCdude" has never even written a prescription!

Diabeticfootdr, thanks for your confirmation of my comments based on your significant knowledge and expertise. As per Diabeticfootdr's post, ONLY Cymbalta and Lyrica are FDA approved for diabetic neuropathy. Neurontin/gababentin is FDA approved for post herpetic neurlagia. So where do you come up with this "gold standard" line and the line "none of the others have been proven effective?" Do you know something that the FDA doesn't??

XCdude, do your research and have some knowledge based on facts prior to putting your foot in your mouth and questioning those with significant clinical experience. It's a good lesson for the future.

 

[XCdude]

Neuroma pain and neuropathy pain are a whole different story!!!!!!!!

That's why in my original post I rambled on about why those meds were not appropriate for neuroma pain.

And I just love when a podiatry student comes on this forum such as "XCdude" and tells me, after over 20 years of practice, that gabapentin/Neurontin is the "gold standard" and "none of the others have even been proven to be effective....."

Yet "XCdude" has never even written a prescription!

Diabeticfootdr, thanks for your confirmation of my comments based on your significant knowledge and expertise. As per Diabeticfootdr's post, ONLY Cymbalta and Lyrica are FDA approved for diabetic neuropathy. Neurontin/gababentin is FDA approved for post herpetic neurlagia. So where do you come up with this "gold standard" line and the line "none of the others have been proven effective?" Do you know something that the FDA doesn't??

XCdude, do your research and have some knowledge based on facts prior to putting your foot in your mouth and questioning those with significant clinical experience. It's a good lesson for the future.

http://www.medicinenet.com/gabapentin-oral/article.htm

http://diabetes.niddk.nih.gov/DM/pubs/neuropathies/#treatment

http://www.merck.com/mmpe/sec16/ch209/ch209a.html#CACIDGIH

I mistaken, and will in the future refrain from chiming in until I am practicing. Different specialists may have different notions of what the standard treatment for neuropathic pain is.

 

[PADPM]

XCdude,

You don't have to be a podiatric student, medical student, dental student or in any medical profession to simply press a button and perform an internet search on medications.

Information found on the internet is certainly not "gospel", nor does it define the "gold standard". It simply relays the information on that particular website. Period.

The term "gold standard" is a very dangerous term to use, since I can think of very few instances in medicine today where there are truly "gold standards". There are so many cross-over medications and technologies, that it is very difficult to back yourself into a corner with one "gold standard".

There are many examples.......is a CT scan the "gold standard" to determine if there is a tarsal coalition? Is a bone biopsy the "gold standard" to determine whether there is truly osteomyelitis? Is joint aspiration/arthrcentesis the "gold standard" to truly determine whether a patient has gout?

The IDEAL answer to many of these questions may be "yes", but sometimes there are other factors involved that may, yes may preclude a doctor from performing a particular procedure initially. That's why "gold standards" can be difficult to define.

In your attempt to contribute to this forum, base your answers on facts that you KNOW, not on information from sources that you are depending on from OTHER peoples knowledge. Otherwise, you are simply regurgitating information that may or may not be correct/accurate. And that's an important lesson to carry on into your career.

Never, never have a conversation with another professional or attempt to be proficient in something you know nothing about, but "read" about. Your lack of knowledge, when talking with an expert will be obvious and embarrassing. Stick with what you know and you'll always be safe and respected.