Suzetrigine

[Taus]

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If you want to do that, just prescribe a single opioid pill. For a one time dose of a medication to improve procedure tolerance, you want to be certain that it works.

I do 1/3 of my procedure in an office setting. I find that a 0.5mg Xanax + 5mg hydrocodone/oxycodone definitely helps non Medicare age patients get through an office based cervical RFA

I’ve thought about that for some office procedures, but concerned about having to deal w nausea/vomiting if opioid naive. I find a higher dose benzo does the trick

 

[bedrock]

I’ve thought about that for some office procedures, but concerned about having to deal w nausea/vomiting if opioid naive. I find a higher dose benzo does the trick

I agree that you do have to consider if they might be opioid naive as you don’t want a nausea issue complicating your case. If they don’t have history of tolerating a specific opioid type after surgery/ER visit, I don’t write an opioid, but I increase the benzo which is similar to you.

However, if the patient can clearly recall that they tolerated a few doses of a specific opioid in the past, then I write for both that opioid and a benzo instead of just the higher dose benzo.
I still find that doing the benzo + opioid combo works better than just a benzo for more uncomfortable office based procedures such as cervical RFA/SCS trial/kyphoplasty.

 

[bedrock]

I’ve thought about that for some office procedures, but concerned about having to deal w nausea/vomiting if opioid naive. I find a higher dose benzo does the trick

I am a bit intrigued by the MKO Melt tablet you posted about previously.

Has anyone here used MKO melt for pain cases?

Can some of the anesthesiologists here please share their thoughts on the safety of the ketamine dose in MKO Melt for less healthy patients?

 

[Laryngospasm]

Ketamine is the one true anesthetic to rule them all.. but if a patient has a bad trip lord help you lol. Although this is unlikely on a small dose. Patients can be next to impossible to control without iv sedation if they have bad reaction to it.

 

[1 Up]

Ketamine is the one true anesthetic to rule them all.. but if a patient has a bad trip lord help you lol. Although this is unlikely on a small dose. Patients can be next to impossible to control without iv sedation if they have bad reaction to it.

Had a gal take a 90 second trip to Hell and back with a 10 mg push this week. And she let us know (including every patient down the hallway) for all 90 seconds of it. It was... entertaining...

 

[$hadow]

I’ve taken hydrocodone for post op pain. I couldn’t tell I took anything. When I take ibuprofen I get relief. Also of note no euphoria at all with hydrocodone. I have also taken oxycodone for post op pain. Significant pain relief and notable euphoria.

my experience was like MitchLevi.

I've taken hydrocodone and oxycodone for various knee surgeries

No real benefit and really bad constipation...


because its early and no one is here:

Nonopioid versus opioid analgesia after hospital discharge following cesarean delivery: a randomized equivalence trial - PubMed

Pain score 2-4 weeks after cesarean delivery was lower in women receiving nonopioid analgesics.

pubmed.ncbi.nlm.nih.gov

c section. but thats not painful, right?

Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial - PubMed

In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective...

pubmed.ncbi.nlm.nih.gov

no difference in satisfaction scores (agree, not truly pain scores but significant nevertheless)

Prospective Randomized Trial Comparing Opioids versus Nonsteroidal Antiinflammatory Drugs for Postoperative Analgesia in Outpatient Rhinoplasty - PubMed

Therapeutic, II.

pubmed.ncbi.nlm.nih.gov

rhinoplasty. ibuprofen was not inferior to hydrocodone

Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial - PubMed

clinicaltrials.gov Identifier: NCT02455518.

pubmed.ncbi.nlm.nih.gov

single dose, in ER acute extremity pain. no difference at 2 hours between ibuprofen and oral opioid.

A Randomized Trial Comparing the Efficacy of Five Oral Analgesics for Treatment of Acute Musculoskeletal Extremity Pain in the Emergency Department - PubMed

No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.

pubmed.ncbi.nlm.nih.gov

kind of a garbage study, but opioids were not superior to ibuprofen.

but for extremity fractures, which are probably in bedrocks world not as painful as spine surgery, so i guess we should throw this out for that reason.

along with all the other studies that dont align with any preconceived notions.

Is this not expected in approximately 5-10% of caucasians? I have also read somewhere that up to 20% of East Asian populations have this as well.

I did some light reading a while back and found CYP2D6 is responsible for codeine, hydrocodone and tramadol metabolism and some people do not have sufficient levels of this enzyme to promote conversion to their active substances (poor metabolisers).

1-2% of Middle Eastern populations (and another one I do not remember) are the opposite; they are rapid metabolisers.

Oxycodone is primarily metabolized by CYP3A4 and CYP2D6 to some degree, so is less commonly effected.

 

[au bon pain]

I am a bit intrigued by the MKO Melt tablet you posted about previously.

Has anyone here used MKO melt for pain cases?

Can some of the anesthesiologists here please share their thoughts on the safety of the ketamine dose in MKO Melt for less healthy patients?

Curious also so will bump — anybody have 1st hand experience using MKO Melts for cases?

 

[lobelsteve]

From NEJM article. As it was 48 hour study, the scores used were calculated as difference from baseline. Drug looks a lot less impressive if you compare it at same time point to placebo over the course of 48 hours.

 

[clubdeac]

View attachment 404057

From NEJM article. As it was 48 hour study, the scores used were calculated as difference from baseline. Drug looks a lot less impressive if you compare it at same time point to placebo over the course of 48 hours.

It always amazes me how well placebo does in these studies

 

[joshmir]

Steve, thanks for posting that

I’ve been meaning to look at the studies to see if they put local anesthetic in the incisions, and in the case of the bunionectomy surgeries, did they do an ankle block?

In the latter case, that would make differentiation between suzetrigine and whatever it’s compared against more tricky

 

[lobelsteve]

Steve, thanks for posting that

I’ve been meaning to look at the studies to see if they put local anesthetic in the incisions, and in the case of the bunionectomy surgeries, did they do an ankle block?

In the latter case, that would make differentiation between suzetrigine and whatever it’s compared against more tricky

Key Inclusion Criteria:

• Before Surgery
  
  • Participants scheduled to undergo a primary unilateral bunionectomy with distal first metatarsal osteotomy (i.e., Austin procedure) and internal fixation under regional anesthesia (Mayo and popliteal sciatic block)
• After Surgery
  
  • Participant is lucid and able to follow commands
  • All analgesic guidelines were followed during and after the bunionectomy

Key Exclusion Criteria:

• Before Surgery
  
  • Prior history of bunionectomy or or other foot surgery on the index foot; or bunionectomy on the opposite foot
  • History of cardiac dysrhythmias within the last 2 years requiring anti-arrhythmia treatment(s)
  • Any prior surgery within 1 month before the first study drug dose
• After Surgery
  
  • Participant had a type 3 deformity requiring a base wedge osteotomy, concomitant surgery such as hammertoe repair; or experienced medical complications during the bunionectomy
  • Participant had a medical complication during the bunionectomy that, in the opinion of the investigator, should preclude randomization

Other protocol defined Inclusion/Exclusion criteria may apply.

 

[MitchLevi]

Not sure how this became so prevalent on social media and how it filtered into the minds of several of my pts leading to questions about my giving it to them. Chronic back pain it’s asked me about this, so did peripheral neuropathy pts.

 

[Taus]

Not sure how this became so prevalent on social media and how it filtered into the minds of several of my pts leading to questions about my giving it to them. Chronic back pain it’s asked me about this, so did peripheral neuropathy pts.

Same. I really have no reason not to try it outside of adding to mg my staffs workload doing prior auth.

 

[bedrock]

Same. I really have no reason not to try it outside of adding to mg my staffs workload doing prior auth.

Not sure how this became so prevalent on social media and how it filtered into the minds of several of my pts leading to questions about my giving it to them. Chronic back pain it’s asked me about this, so did peripheral neuropathy pts.

Thanks guys. I saw there were more posts in this thread and wanted to check it out.

I’m just not understanding when this medication would be more useful than what we already have (and doesn’t require us to pay our staff to deal with pre auth BS) ?

 

[MitchLevi]

Thanks guys. I saw there were more posts in this thread and wanted to check it out.

I’m just not understanding when this medication would be more useful than what we already have (and doesn’t require us to pay our staff to deal with pre auth BS) ?

It was studied after bunionectomy and abdominoplasty…Fine. Study it for other things I guess? Has no bearing on our field.

 

[BobBarker]

You guys aren’t listening. It doesn’t take any staff time. It will lower your pill count, meq count, make YOU look better on paper.

 

[MitchLevi]

You guys aren’t listening. It doesn’t take any staff time. It will lower your pill count, meq count, make YOU look better on paper.

I’m happy to try it, but I need something that defends my using it in my pt population. If it causes any problems I need to be able to defend it.

 

[BobBarker]

There is much less risk with prescribing Journavx vs turning up your patient already on MSER and hydrocodone after their tka.

 

[callmeanesthesia]

I bet we could Rx for acute post-procedural pain for post-RF and use it as an adjunct to procedural sedation as well. Have them start it the day before the procedure, take a Xanax along with it an hour before the procedure. Bet it would help a lot with neuritis…

 

[Taus]

Thanks guys. I saw there were more posts in this thread and wanted to check it out.

I’m just not understanding when this medication would be more useful than what we already have (and doesn’t require us to pay our staff to deal with pre auth BS) ?

I will try it in a situation where I would have otherwise Rx’d hydro/oxy short term. But gives me nucynta vibes. I really liked nucynta instead of traditional mu agonists, but it was such a pain in the ass despite the rebate/discount cards that I abandoned it years ago.

 

[bedrock]

I will try it in a situation where I would have otherwise Rx’d hydro/oxy short term. But gives me nucynta vibes. I really liked nucynta instead of traditional mu agonists, but it was such a pain in the ass despite the rebate/discount cards that I abandoned it years ago.

Ah, that is helpful. I was the same with nucynta and also stopped for the same reason as you. As someone said above, if pharm companies werent so greedy, they could sell a lot of scripts at a medium price instead of very very few at a really high price.

 

[bedrock]

There is much less risk with prescribing Journavx vs turning up your patient already on MSER and hydrocodone after their tka.

Understood. But if i'm not writing for chronic opioids now, I'm not sure where this would be useful?
Right now I write a lot of gaba/lyrica, tramadol,with a few celebrex,/lidoderm/elavil and various muscle relaxants. , etc.

Very very rarely write opioids, typically just a few days after intracept or cervical RFA.

 

[BobBarker]

Big difference. Nucynta 100mg has a meq of 40mg. Journavx is 0.

 

[bedrock]

Big difference. Nucynta 100mg has a meq of 40mg. Journavx is 0.

Everyone knows the meq of nucynta is BS, and not realistic.

Regarding journavx, 1- how reliably does it relieve pain compared to other meds
2-how frequently do you see significant side effects?

Every drug has a patient that will have an adverse effect, but in the setting of meds for a few days of post procedural pain, if I need something more than nsaid/lyrica/tramadol, I’m then writing for an opioid typically Norco.

So I just don’t think the juice is worth the squeeze for a script of a week or less.

I’m more open to writing it for chronic pain if there is something this treats noticeably better than other non opioid meds.

 

[Ducttape]

Not sure how this became so prevalent on social media and how it filtered into the minds of several of my pts leading to questions about my giving it to them. Chronic back pain it’s asked me about this, so did peripheral neuropathy pts.

"pain" influencers reading it on "fake news" then posting about it on all the social media sites.

Everyone knows the meq of nucynta is BS, and not realistic.

Regarding journavx, 1- how reliably does it relieve pain compared to other meds
2-how frequently do you see significant side effects?

Every drug has a patient that will have an adverse effect, but in the setting of meds for a few days of post procedural pain, if I need something more than nsaid/lyrica/tramadol, I’m then writing for an opioid typically Norco.

So I just don’t think the juice is worth the squeeze for a script of a week or less.

I’m more open to writing it for chronic pain if there is something this treats noticeably better than other non opioid meds.

seems like this is the only time to write for this drug is for 1 week for post op pain. not for chronic pain.


but just give it time. in order to extend their patent, in about 5 years the company will post a study that shows it is not inferior to norco for chronic pain of some sort.

 

[BobBarker]

Yes, certainly. Then it will be or the next iteration are most commonly prescribed drug. Similar to when eliquis took over for warfarin for afib.