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Update on Chronic Neuropathic Pain Medications Joyce Côté, BSc Pharm ACPR Pharmacist, Chronic Pain Centre January 16, 2013 Calgary Neuropathy Association.

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Presentation on theme: "Update on Chronic Neuropathic Pain Medications Joyce Côté, BSc Pharm ACPR Pharmacist, Chronic Pain Centre January 16, 2013 Calgary Neuropathy Association."— Presentation transcript:

1 Update on Chronic Neuropathic Pain Medications Joyce Côté, BSc Pharm ACPR Pharmacist, Chronic Pain Centre January 16, 2013 Calgary Neuropathy Association Presentation

2 2 Outline Medication Goals and Patients Toolbox Antidepressants Anticonvulsants Opioids Cannabinoids Medical marijuana

3 3 Goals of Medication Therapy 30% pain relief may be expected Increase function Balance pain relief with acceptable side effects

4 4 Patients Toolbox Rehabilitation Self-Monitoring Pacing Relaxation Self-Talk Communication Self- Management Medications Knowledge Nutrition

5 5 ANTIDEPRESSANTS – TRICYCLIC

6 6 Antidepressants – Tricyclic Amitriptyline (Elavil®), Nortriptyline (Aventyl®), Desipramine (Norpramin®) 1 st line for neuropathic pain Increase levels of serotonin and norepinephrine May also be helpful for sleep, mood, and migraine prevention Side Effects: –Drowsiness, dizziness, blurred vision, constipation, difficulty urinating, weight gain

7 7 Amitriptyline Alberta Blue Cross – Regular Benefits 10 mg tablet $0.06 25 mg tablet $0.12 50 mg tablet $0.23 75 mg tablet $0.36

8 8 Nortriptyline Alberta Blue Cross – Regular Benefits 10 mg capsule $0.09 25 mg capsule $0.18

9 9 Desipramine Alberta Blue Cross – Regular Benefits 10 mg tablet $0.38 25 mg tablet $0.38 50 mg tablet $0.67 75 mg tablet $0.89

10 10 ANTIDEPRESSANTS – SNRI

11 11 Antidepressants – SNRI SNRI = Serotonin and Norepinephrine Reuptake Inhibitor Increase serotonin and norepinephrine Venlafaxine (Effexor®), duloxetine (Cymbalta®) Side Effects: –Nausea, headache, increased blood pressure Withdrawal effects are common with venlafaxine

12 12 Venlafaxine Alberta Blue Cross – Regular Benefits 37.5 mg capsule $0.35 75 mg capsule $0.70 150 mg capsule $0.73

13 13 Duloxetine Health Canada Indications –Major depressive disorder –Diabetic peripheral neuropathic pain –General anxiety disorder –Fibromyalgia –Chronic low back pain –Osteoarthritis of the knee (July 2012)

14 14 Duloxetine Alberta Blue Cross – Regular Benefit 30 mg capsule $1.88 60 mg capsule $3.75

15 15 ANTIEPILEPTICS – 1 ST LINE

16 16 Antiepileptics – 1 st Line Gabapentin (Neurontin®), pregabalin (Lyrica®) 1 st line for neuropathic pain Side Effects: –Drowsiness, dizziness, unsteadiness, unable to think clearly, weight gain

17 17 Gabapentin Alberta Blue Cross – Regular Benefits 100 mg capsule $0.16 300 mg capsule $0.39 400 mg capsule $0.46 Alberta Blue Cross – Not Benefits 600 mg tablet ~$1.30 800 mg tablet ~$1.74

18 18 Pregabalin Health Canada Indications –Diabetic peripheral neuropathy –Postherpetic neuralgia –Spinal cord injury neuropathic pain –Fibromyalgia

19 19 Pregabalin Alberta Blue Cross – Not Benefits 25 mg capsule ~$0.85 50 mg capsule ~$1.30 75 mg capsule ~$1.74 150 mg capsule ~$2.39 300 mg capsule ~$2.41 Generics expected to be available ~Sept 2013

20 20 ANTIEPILEPTICS – OTHER

21 21 Antiepileptics – Other Topiramate (Topamax®), lamotrogine (Lamictal®), carbamazepine (Tegretol®), oxcarbazepine (Trileptal®), divalproex (Epival®)

22 22 Topiramate (Topamax®) Also useful for prevention of migraine headaches Side Effects: –Drowsiness, dizziness –Memory difficulties, confusion –Loss of appetite, nausea –Burning/tingling/numbness in hands/feet

23 23 Topiramate Alberta Blue Cross – Regular Benefits 25 mg tablet $0.48 50 mg tablet (PMS Only – pale yellow) $1.07 100 mg tablet $0.91 200 mg tablet $1.36 15 mg sprinkle capsule $1.17 25 mg sprinkle capsule $1.23

24 24 OPIOIDS

25 25 Opioids Canadian Opioid Guidelines –Opioids showed only small to moderate benefits for neuropathic pain. Some opioids are marketed specifically for neuropathic pain due to additional mechanisms of action –Tramadol –Tapentadol –Methadone

26 26 Opioids Common side effects: –Drowsiness, dizziness, nausea, constipation, itching Serious side effects: –Breathing slows down Long-term complications: –Sleep apnea –Decrease in sex hormones –Opioid-induced hyperalgesia

27 27 Tramadol Long-Acting Also increases serotonin and norepinephrine Ralivia® Tridural® –25% immediate-release Zytram XL® Durela®) –17 to 25% immediate-release

28 28 Ralivia® 100 mg tablet ~$1.32 200 mg tablet ~$2.39 300 mg tablet ~$3.48

29 29 Tridural® 100 mg tablet ~$1.26 200 mg tablet ~$2.31 300 mg ~$3.26

30 30 Zytram XL® 75 mg tablet ~$0.91 100 mg ~$1.18 150 mg ~$1.71 300 mg ~$3.26 400 mg ~$4.28

31 31 Durela® 100 mg capsule ~$1.22 200 mg capsule ~$2.23 300 mg capsule ~$3.23

32 32 Tapentadol CR (Nucynta CR®) Moderate-severe pain Mu-opioid agonist plus norepinephrine reuptake inhibition (NRI) Possibly better GI tolerability Possibly more norepinephrine-like side effects Maximum dose

33 33 Tapentadol CR Alberta Blue Cross – Not a Benefit 50 mg CR ~$1.03 100 mg CR 150 mg CR 200 mg CR 250 mg CR ~$3.71

34 34 Methadone (Metadol ® ) Two distinct indications: –Pain –Opioid-dependence / addiction For pain: Opioid activity Serotonin and norepinephrine reuptake inhibition NMDA receptor antagonist NMDA = N-methyl-D-aspartate

35 35 Methadone Long-acting Inexpensive Electrocardiogram required Requires frequent monitoring while adjusting the dose Lots of drug interactions Risk of overdose is higher Physician requires a special license

36 36 Methadone Alberta Blue Cross – Regular Benefit 1 mg tab $0.17 5 mg tab $0.56 10 mg tab $0.90 25 mg tab $1.69 1 mg/mL oral solution $0.10/mL 10 mg/mL oral solution $0.37/mL

37 37 CANNABINOIDS

38 38 Cannabinoids Nabilone (Cesamet®), tetrahydrocannabinol- cannabidiol (Sativex®) Side effects: –Drowsiness, dizziness, unsteadiness, dry mouth

39 39 Nabilone (Cesamet®) Health Canada indicated for nausea and vomiting associated with chemotherapy Studied in fibromyalgia (1 mg twice daily x 4 weeks) Studied in diabetic peripheral neuropathic pain (1-4 mg/day x 9 weeks)

40 40 Nabilone Alberta Blue Cross – Regular Benefits 0.5 mg capsule $3.10 (generic $1.17) 1 mg capsule $6.21 (generic $2.33)

41 41 Tetrahydrocannabinol-cannabidiol (Sativex®) Spray under tongue or inside cheek Usually 8 sprays/day Alberta Blue Cross – Not a Benefit Vials of 48 sprays = ~$125

42 42 MEDICAL MARIJUANA

43 43 Medical Marijuana Health Canada: –Marijuana is not an approved therapeutic product –Its safety and efficacy have not been established –Use… involves risks to health, some of which may not be known or fully understood

44 44 Medical Marijuana What it does: –Often produces euphoria, relaxation, time-distortion, perception of enhanced sensory experiences, and loss of inhibitions What the active ingredients might be: –Tetrahydrocannabinol (THC) –Cannabinol –Cannabidiol

45 45 Medical Marijuana What the other ingredients might be: –There may be more than 60 other cannabinoids –Many of the substances found in tobacco smoke have been found in marijuana smoke

46 46 Medical Marijuana Warnings: –Heart disease –Asthma, chronic obstructive pulmonary disease –Alcohol/drug abuse or dependence –Serious mental disorders Administration by smoking is not recommended –Some people use in food, tea, or with a vaporizer May impair your ability to drive –Can last up to 24 hours after consuming

47 47 Medical Marijuana Side Effects: –Mood reactions such as anxiety, paranoia, agitation, amnesia, delusions or hallucinations –Fast heartbeat –Facial flushing or red eyes –Dizziness or feeling faint Long-Term Complications: –Wheezing or chronic cough if smoked –May impair short-term memory, attention, and concentration

48 48 Medical Marijuana Drug Interactions –Any drugs that slow down the central nervous system, causing drowsiness E.g. sleeping pills –Antiviral drugs used in the treatment of AIDS

49 49 Medical Marijuana Application Process Two Categories –Category 1 – specialist not needed –Category 2 – specialist required Authorization renewal required yearly Marihuana Medical Access Division: –www.healthcanada.gc.ca/mma or 1-866-337-7705www.healthcanada.gc.ca/mma

50 50 Medical Marijuana Distribution –Delivery every month by courier to your home or doctors office Cost –30 seeds = $20 –Dried marijuana = $5/gram

51 51 Medical Marijuana College of Physicians and Surgeons of Alberta Jan 2012: –marijuana remains an illegal drug; one that is not on any formulary and one that has no human evidence as to efficacy, dose or safety. –In the absence of evidence as to efficacy, we will continue to counsel our members not to authorize (orprescribe) [medical marijuana] for medical purposes.

52 52 Medical Marijuana Proposed changes December 16, 2012 Removes Health Canada as a gatekeeper Doctors fill out a medical document similar to a prescription No specialist consult doctor required Patients takes document to a licensed producer Removal of home production

53 53 Medical Marijuana Canadian Medical Association: –Theres a huge potential for harm to patients and the federal governments decision is equivalent to asking doctors to prescribe while blindfolded.

54 54 Medical Marijuana Currently > 26, 000 patients across Canada with authorized use (<500 patients in 2002) Cost will increase to ~ $8.80/gram (from $1.80 to $5/gram) Federal Health Minister Leona Aglukkaq: –Individuals will be able to choose their licensed producer based on strength, price, quality and customer service

55 55 Medical Marijuana Health Canada will keep its current contract until March 31, 2014 to continue current patients Health Canada will align the price of its own supply once licensed producers are approved No new applications after October 1, 2013 April 1, 2014: Health Canada would no longer produce/sell marijuana

56 56 Medical Marijuana Producers are subject to security requirements, inspections, and good manufacturing practices –Indoor production site (not a private residence) –Restricted access –24/7 camera security system and alarm system –Valid security clearance –Notify local police, fire, and government officals

57 57 Medical Marijuana Governments goal is to have new guidelines by March 31, 2013, and full implementation by April 2014 Canadians have the opportunity to comment before Feb 28, 2013. Comments or concerns you might have regarding the proposed changes can be submitted to Health Canada via email to consultations-marihuana@hc-sc.gc.ca.consultations-marihuana@hc-sc.gc.ca

58 58 TOPICAL ANALGESICS

59 59 Topical Lidocaine 5% ointment commercially available, 30 grams –Applied 3-4 times daily as needed –Requires prescription –May be compounded with other drugs and using different bases Alberta Blue Cross – Regular Benefit –$0.15/gram topical ointment

60 60 Topical Capsaicin Capsaicin 0.075% cream (Zostrix HP) –Painful diabetic foot neuropathy –Applied four times daily regularly –Decreases pain intensity –Well tolerated after initial few days –Available over-the-counter ~$31 per 60 grams

61 61 Topical Ketamine Requires a triplicate prescription Needs to be made by a compounding pharmacy Helpful for: –Allodynia (pain produced by a stimulus which does not normally cause pain, e.g. light touch) –Hyperalgesia (increased sensitivity to pain)

62 62 PATIENT RESOURCES

63 63 Patient Resources Chronic Pain Centre Public Lectures www.albertahealthservices.ca/2790.asp www.albertahealthservices.ca/2790.asp –Introduction to pain –This is your body –Medications –The role of exercise in managing pain –Attention and memory –Nutrition –Pacing in pain management –Anxiety, depression and chronic pain –Sleep –Understanding medical investigations and the health care system

64 64 Pain Resources Canadian Pain Coalition www.canadianpaincoalition.ca www.canadianpaincoalition.ca –Conquering Pain for Canadians booklet –Pain Resource Centre

65 65 THANK YOU!


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