Reconciling Combination Therapy With EBM: Where Do We Go From Here?
Weighing Combination Approaches To Neuropathy
Years ago, there were few treatment options for neuropathy, a common symptom of uncontrolled diabetes, and patients often left the office without a prescription in hand. Physicians would lend a sympathetic ear but had little more than oral tricyclic antidepressants to use and these were not always successful in curbing the progression of painful neuropathy. Pharmaceutical companies recognized that and have now offered other oral medications including anti-epileptics such as pregabalin (Lyrica™, Pfizer) and antidepressants including duloxetine HCl (Cymbalta™, Eli Lilly). However, not every podiatrist is equally comfortable in prescribing these medications for their patients and would like an alternative with fewer side effects. The concept of the compounding pharmacy is to alter, combine and create new formulations of medications, which is the very essence of combination therapies. Physicians with practices that concentrate on neuropathic treatments, both medical and surgical, have found value in compounded preparations for the treatment of painful neuropathy. Serrina Yozsa, DPM, of Scottsdale, Ariz., lectured at the American Association for Women Podiatrists meeting in Colorado recently. While she often utilizes a full range of oral medications and may perform surgical nerve decompression to help restore sensation to the neuropathic patient with diabetes, Dr. Yozsa has also turned to the compounding pharmacy for practical answers. She recommends a compound topical formulation of ketoprofen (Oruvail®, Wyeth), gabapentin and clonidine. Kimberly Eickmeier, DPM, another respected lecturer and noted surgeon, recommends a similar compounded formulation of gabapentin, amitriptyline (Elavil, AstraZeneca) and ketamine for the topical treatment of neuropathic pain. Topical treatments for neuropathic pain eliminate the possibility of systemic side effects when patients take oral medications. Indeed, some patients have described adverse effects with gabapentin at a severity level that caused them to discontinue the medication prior to achieving any beneficial effects. Topical administration avoids central nervous system complications. Similarly, ketamine is known for creating psychosis when clinicians use it as an intravenous anesthetic.