Switching Companies Mid Trial for failed trials?

[Timeoutofmind]

I have heard docs saying they do this.

I typically do a five day trial, say Nevro. Would you just call the rep from Abbott up on day 5 when the patient is in the office and have them meet up to switch things up? Then leave it in for another five days? Aren't you worried about the infection risk of leaving it in 10 days in this scenario?

Or do you usually just give them 3-4 days with a company and call them and if no better, switch it over for the second 3-4 days? Most of the reps want at least a five day trial in my experience...

Thanks in advance.

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[unchockey21]

I have heard docs saying they do this.

I typically do a five day trial, say Nevro. Would you just call the rep from Abbott up on day 5 when the patient is in the office and have them meet up to switch things up? Then leave it in for another five days? Aren't you worried about the infection risk of leaving it in 10 days in this scenario?

Or do you usually just give them 3-4 days with a company and call them and if no better, switch it over for the second 3-4 days? Most of the reps want at least a five day trial in my experience...

Thanks in advance.

We did it in fellowship. We did 7 Day trials. Some people would come in early on day 5 if they had got nothing so far, others would just come in on day 7 like they normally would. We’d call rep up if patient was game and extend it another 3-5 days. No data that I know of showing increased risk extending trial. I’ve been anecdotally told they trial longer in Europe but I couldn’t point you to a study or anything concrete.

 

[DOctorJay]

were you involved in the swap out at all? did you or the attending take down the dressings or leave it all up to the reps?

 

[lobelsteve]

OMG that is so 2006.

 

[unchockey21]

were you involved in the swap out at all? did you or the attending take down the dressings or leave it all up to the reps?

We did it. Wouldn’t trust their grubby mits on them alone.

 

[244913]

I haven't done this since being out, but we would do it in fellowship. Pretty low yield in my experience and I worry even more about placebo effect with a mid trial switch. 10 days is my absolute max for a perc trial and that is with a sterile dressing change, scrub down. The guys in Europe are doing perm trials with a tunneled lead.

 

[Orin]

Did it in fellowship and it made sense to me in the rare circumstance where there was an in between case where the leads haven't migrated. In practice I haven't had to do this often.

The infection risk does seem to increase in the literature beyond day 5, so we would assess the entry site, prep/clean it, and redress it.

Practically speaking, I would recommend a paresthesia trial first followed by a paresthesia free system after, primarily to appropriately map the leads for a paresthesia program, but also because conventional low frequency stimulation should work quicker, so a 3-5 day trial is okay for it. The higher frequency stim people suggest a 48-72h wash in period so you would want to go 5-7 days if you're making changes.

I often fear that the decision to call a trial a success, a failure, or equivocal says more about the people involved in the decision making process than anything completely objective like pain scores/function/medication usage.

 

[jpb26]

I actually talked to a patient about this today - failed Nevro trial and talked to her about connecting Medtronic. I have done this occasionally in the past but only rarely mostly because Im worried about placebo effect and the extended trial. When I have done this I agree its been low yield.

Am I right in saying some systems aren't compatible with each other?

 

[Orin]

Am I right in saying some systems aren't compatible with each other?

As far as I have been told by the reps, they have external adapters for their competitor's leads to work with their trial pulse generators. Boston has their "Observational Mechanical Gateway" (OMG) which definitely works with Abbot/Medtronic and probably Nevro. I know Medtronic has stuff that works with Nevro's leads.

 

[painfree23]

is a re-trial with another company a few weeks later reasonable?

 

[lobelsteve]

is a re-trial with another company a few weeks later reasonable?

Not if i am paying. Or insurance.

 

[gdub25]

I trial with Nevro almost exclusively but anytime a patient is 4 days in with little to no response we bring them in for an X-ray and if leads have not migrated we give another waveform a try with another company. I don’t have to do this often, but in the current market I don’t think any patient should fail a trial without being able to try two different waveforms. I’ve had enough people fail Nevro and get substantial relief with Burst afterwards that I truly believe there is no “one size fits all” mode of stimulation. The Burst data isn’t very good long term so I have followed these few patients closely, calling them every 3 months myself to see how they are really doing and so far relief has been sustained.