Key Insights On Using Medications In Wound Care

When it comes to patients with wounds, medications and supplements may help abate the pain and spur healing. These expert panelists discuss key considerations with the use of supplements and pharmaceuticals for wound pain and neuropathic wounds.

Q: What medications or supplements do you use for wound pain?

A: For Kazu Suzuki, DPM, CWS, appropriate wound debridement and applying a moist wound dressing are the most important keys in managing wound pain. For wound pain associated with debridement, Lee C. Rogers, DPM, suggests applying topical lidocaine gel or lidocaine soaked gauze. If this is insufficient, he says injecting an anesthetic in the periulcerative area or performing debridement in the OR can mitigate the pain.

   If the wound pain results from a dressing change, Dr. Rogers uses a non-adherent dressing such as Mepilex or Mepitel (Molnlycke) with Safetac silicone technology. He says an alternative would be soaking the dressing with an anesthetic prior to removal. For patients with pain due to VAC therapy (KCI) dressing changes, he notes one can turn off the suction, infiltrate the foam with lidocaine and let it set for a few minutes.

   Kathy Satterfield, DPM, says there is often a misperception that all wound patients are insensate but notes this is obviously not always the case. She treats patients’ wound pain “very aggressively,” often doing so in concert with physicians at pain clinics.

   If patients do not have pain relief with a hydrocodone/acetaminophen tablet (Vicodin, Abbott Laboratories) on a TID to QID basis, Dr. Satterfield refers them to a pain clinic. If the patient needs an additional modality such as a fentanyl patch for pain management, she defers to the pain management specialist.

   “It is good for referrals. It is good practice. It is just good medicine,” she notes.

   When it comes to pain medication, Dr. Suzuki uses an escalating approach that he learned from a pain management doctor. He will start with acetaminophen (Tylenol, McNeil) 1,000 mg four times a day. If this is not effective, Dr. Suzuki will consider hydrocodone/acetaminophen 5/500, 7.5/750, 10/660. If the pain continues unabated, he will consider oxycodone/acetaminophen (Percocet, Endo Pharmaceuticals) 5/325, 10/650.

   Sometimes Dr. Suzuki might prescribe extended-release oxycodone (Oxycontin, Purdue Pharma) if the patient has chronic pain and has been on opioid medications for a long time. If that is not enough, he will not hesitate to send patients to the pain management clinic as they may benefit from a transdermal pain patch or spinal injections of anesthetic/steroid medication.

Q: What drugs do you use to treat neuropathic pain?

A: Although there are several drugs that physicians may utilize for painful diabetic neuropathy (PDN), Dr. Rogers notes only two drugs have a FDA indication for this type of pain. These drugs are duloxetine (Cymbalta, Eli Lilly) and pregabalin (Lyrica, Pfizer). Dr. Suzuki mostly prescribes pregabalin 50 mg (starting with qhs and titrating up to TID) and duloxetine 30 mg (starting with QD for one week and then titrating up to 60 mg QD). He may add acetaminophen and opioid pain medications if the pain is severe but Dr. Suzuki says opioids should be a last resort.

   Dr. Rogers says other drugs that are commonly used without specific PDN indications are amitriptyline (Elavil, AstraZeneca), gabapentin (Neurontin, Pfizer), tramadol (Ultram, Ortho-McNeil) and oxycodone.

   Dr. Rogers notes that reviews of drug efficacies using the number needed to treat (NNT) can provide some guidance. He emphasizes caution when it comes to ensuring proper dosing. Dr. Rogers points out that dosing used in clinical trials is often higher than the dosing noted in the indications for the given drug, and dosing can vary depending upon what you are treating.

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