Reconciling Combination Therapy With EBM: Where Do We Go From Here?
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.
An Overview Of Combination Therapy In Wound Care
The needs of the wound are multi-faceted. Exudates require active control. Contamination requires antimicrobial agents. Angiogenesis requires growth factors to develop. Podiatric physicians need to eliminate harmful matrix metalloproteases from the wound base and hyperkeratotic tissue requires debridement.
At the recent Oklahoma Podiatric Medical Association meeting in Tulsa, there was much discussion about successes enjoyed by practitioners who used VAC therapy (KCI) in concert with other modalities and topical medications (see “Combining VAC Therapy With Advanced Modalities: Can It Expedite Healing?” pages 18-24, September 2005 issue).
Silver dressings have been a longtime choice for use with the VAC in order to control contamination at the interface with the sponge dressing. The spectrum of microbial presence is difficult to assess without laboratory testing. As it progresses from colonization to contamination to critical contamination, the burden on the wound becomes onerous, delaying healing and predisposing the patient to active, overt infection.
The presence of silver, with its known antimicrobial properties, reduces the potential for that infection. Physicians have often utilized Acticoat™ (Smith & Nephew), Silverlon™ and other interface materials between the wound and the sponge. A recent development by KCI, the creators of negative pressure therapy technology, is a silver-impregnated sponge that allows for the same effect achieved by combining products.
The antimicrobial effects of silver have been identified for more than 100 years. Scientific examination has shown that silver is effective against a wide range of organisms, including difficult to treat vancomycin resistant strains, viruses and fungus.
However, researchers have raised concerns recently about the strength of silver and its effects on the wound bed. Multiple studies have found that silver may be toxic to multiple cell types, including keratinocytes and fibroblasts, at high concentrations. The fibroblasts, in particular, appear to be most sensitive to silver-impregnated dressings.
In response to this concern, Johnson & Johnson developed a lower strength silver dressing, Promogran Prisma™. Practitioners who were uncomfortable with the higher strength products have now incorporated this dressing with VAC therapy.