Prialt hysteresis

[Mister Mxyzptlk]

Due to stupid Medicare rules (hopefully due to change) I can't put Prialt in a pump in combo with other drugs. Therefore I have been leaving people on their opioids and putting in Prialt pumps. The main thing I've noticed is the delayed CNS changes, 2-3 weeks after implant.

I have read about delayed CNS impairment but I have a guy who, 3 weeks after implant, developed both CNS and GU problems. First he had urinary retention, then incontinence. I've tracked him closely and I don't think this is a cauda equina type situation. Turning down the rate resolved the CNS symptoms pretty well but the resolution of GU incontinence has been prolonged. After two days he says he can control his bladder about 75% of the time.

Anyone else seen this? I don't have a lot of experience with pure Prialt - usually have just added it to pumps 1 mcg/mL at a time. The prescribing info says you can titrate it 2-3 times per week but if there is this much delayed reaction I'm not so sure.

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[Tenesma]

you are a bigger man than me.... i was burned too many times w/ Prialt weird reactions... too many headaches...

of course, there is a recent article suggesting that intrathecal pumps w/ prialt should be the first step in managing back pain - courtesy of our friend dr deer.

 

[Mister Mxyzptlk]

you are a bigger man than me.... i was burned too many times w/ Prialt weird reactions... too many headaches...

of course, there is a recent article suggesting that intrathecal pumps w/ prialt should be the first step in managing back pain - courtesy of our friend dr deer.

Not bigger, slower. I'm catching up to your experience. It's just weird how the reactions come on so slowly and take so long to respond to changes.

It's doing more than just tickle receptors. It's changing something and the changes take time to occur and to dissipate.

 

[Tenesma]

it's called a cone snail TOXIN for a reason 🙂

 

[Mister Mxyzptlk]

Botulinum toxin irreversibly binds. I think Prialt is felt to not do so because it should be cleaved by endopeptidases but I don't know enough about the basic science literature to know if that is really the case. Botox is a peptide as well and that sure doesn't stop it from hanging in there..

OTOH, maybe it's an ASA type of phenomenon whereby the drug makes an irreversible intracellular change that can only be undone by turnover of new receptors or other cellular components.

Whatever the mechanism, Prialt titration appears to be more like steering an ocean liner than a motorcycle. It's like hydrocodone vs methadone.

If I keep doing this I will make very small changes over very long periods of time. The crap in the prescribing literature about going up 2-3 times per week is garbage.

 

[epidural man]

Due to stupid Medicare rules (hopefully due to change) I can't put Prialt in a pump in combo with other drugs. Therefore I have been leaving people on their opioids and putting in Prialt pumps. The main thing I've noticed is the delayed CNS changes, 2-3 weeks after implant.

I have read about delayed CNS impairment but I have a guy who, 3 weeks after implant, developed both CNS and GU problems. First he had urinary retention, then incontinence. I've tracked him closely and I don't think this is a cauda equina type situation. Turning down the rate resolved the CNS symptoms pretty well but the resolution of GU incontinence has been prolonged. After two days he says he can control his bladder about 75% of the time.

Anyone else seen this? I don't have a lot of experience with pure Prialt - usually have just added it to pumps 1 mcg/mL at a time. The prescribing info says you can titrate it 2-3 times per week but if there is this much delayed reaction I'm not so sure.

I have nothing useful to add to this conversation -

But I love the word hysteresis - nice use!

I had a patient on prialt that had auditory hallucination of symphonies...that's kinda cool.

Polyanelgesic Consensus Panel - or whatever the hell their name is - has had prialt 1rst line therapy for many years now.