Navigating Pain Management Prescriptions In Wound Care
Offering insights and perspectives on prescribing medication for patients with painful wounds, these expert panelists discuss drugs for neuropathic pain, extended-release narcotics and how to be wary of pain medication “seekers.”
Do you use gabapentin (Neurontin, Pfizer), pregabalin (Lyrica, Pfizer), or duloxetine (Cymbalta, Eli Lilly) and other medications for neuropathic pain?
“I would estimate that not a day goes by in which I have not prescribed antinociceptive therapy for neuropathic pain,” says Allen Jacobs, DPM.
Most frequently, Dr. Jacobs utilizes gabapentin or amitriptyline. He emphasizes the importance of remembering that these drugs may be helpful in resolving symptoms such as paresthesia or dysesthesia, but do not interdict the actual progression of the disease process. One typically initiates these agents at a lower dose, he says, gradually titrating them until patients achieve pain relief or side effects require discontinuation. Frequently, symptomatic neuropathic symptoms occur during the evening hours, in which case Dr. Jacobs has the patient use the medication one hour prior to bedtime.
It is important to evaluate and document the patient’s response to therapy and any potential side effects, stresses Dr. Jacobs. With gabapentin, he says neuropsychiatric adverse sequelae are most worrisome. With the tricyclic antidepressants (amitriptyline and nortriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine (Effexor, Pfizer), he will check for and document fluid retention, anticholinergic side effects, weight gain, dysrhythmia and other side effects.
Eric Lullove, DPM, uses both gabapentin and pregabalin for neuropathic pain although he notes that gabapentin never received FDA approval for neuropathic pain. Likewise, Kazu Suzuki, DPM, CWS, points out that gabapentin also works well for any other type of pain condition despite its off-label FDA status. Many anesthesiologists and pain management doctors are using such “nerve pain” medications for many pain conditions, says Dr. Suzuki, even though patients may not have diabetes or neuropathic conditions, for which gabapentin has been in use traditionally.
Leon Brill, DPM, CWS, generally starts neuropathic patients on gabapentin 300 mg tid and titrates the dose up to their level of comfort. He will use pregabalin 75 to 150 mg bid as well but finds that patients seem to tolerate gabapentin better in regard to side effects and the drug is more cost-effective. He uses duloxetine 60 mg daily for neuropathic pain, finding it to be most effective in patients who seem to exhibit depressive symptoms.
For Dr. Lullove, loading doses of pregabalin usually start around 75 mg daily, duloxetine doses start at 30 mg daily and gabapentin doses start at 100 mg twice daily. Dr. Suzuki will prescribe gabapentin 100 mg qhs (before bedtime) to start, gradually increasing the dosage until the patient experiences acceptable pain relief. He notes the common side effect of gabapentin is drowsiness, which works well for his patients with pain and sleep problems because of chronic pain.
“I specifically tell patients when starting these medications that drowsiness and lethargy are the primary side effects, mostly in the first three to five days of starting the medication,” says Dr. Lullove. “It is important to communicate to the patients the need to not drive immediately within one to two hours of taking the loading doses of the medications.”
In regard to other medications for the treatment of painful neuropathy, Dr. Brill will prescribe amitriptyline 25 mg at bedtime for patients whose primary pain is at bedtime. Other medications include local treatment with doxepin cream 5% (Zonalon, PharmaDerm) applied topically bid. On occasion, he will use lidocaine patches.