CONCORD INTERNAL MEDICINE Peripheral …...Painful Peripheral Neuropathy Pathway Begin with...

CONCORD INTERNAL MEDICINE

Peripheral Neuropathy

Douglas G. Kelling, Jr., MD C. Gismondi-Eagan, MD, FACP

George C. Monroe, III, MD

April 22, 2012

The information contained in this protocol should never be used as a substitute for clinical judgment. The clinician and the patient need to develop an individual treatment plan that is tailored to the specific needs and circumstances of the patient.

PERIPHERAL NEUROPATHY PROTOCOL TABLE OF CONTENTS

Page(s) PERIPHERAL NUEROPATHY PATHWAY 1 PAINFUL PERIPHERAL NEUROPATHY 2 GABAPENTIN/NEURONTIN PROTOCOL 3-4 PATIENT NOT RELEIVED BY TRICYCLIC ANTIDEPRESSANT OR GABAPENTIN 5-6 DULOXETINE/CYMBALTA PROTOCOL 7 PREGABALIN/LYRICA PROTOCOL 8 CARBAMAZEPINE PROTOCOL 9 LAMOTRIGINE PROTOCOL 10 OXCARBAZEPINE (TRILEPTAL) PROTOCOL 11 AMITRIPTYLINE PROTOCOL 12-14 NORTRIPTYLINE PROTOCOL 15-17 DESIPRAMINE PROTOCOL 18-19

Peripheral Neuropathy Pathway

Monitor response to Semmes-Weinstein 5.07 monofilament and monitor for symptoms of neuropathy (i.e. numbness, pain and/or burning of feet)

Normal sensation and no symptoms

Symptoms and/or absent sensation

Monitor every office visit

Continue to educate

regarding foot care

Check Nerve Conduction studies and consider CBC, CMP, SPEP,

RPR, Sed. Rate, TSH, B12 Level, RBC Folate Level, ANA, 24 hr urine for UPEP, 24 hr. urine for

lead and arsenic and CXR if clinically indicated.

Refer to podiatrist for therapeutic shoes

Treat secondary cause

Evidence of secondary cause of peripheral neuropathy other than diabetes

Yes No

1

Intensive foot care instructions

Consider treating symptoms of pain and/or burning

Refer to Painful Neuropathy Protocol Page 2

Painful Peripheral Neuropathy Pathway

Begin with gabapentin (Neurontin) Increase dose per protocol

Refer to Pages 3 & 4

Pain relieved Pain relief not adequate at maximum dose

Patient intolerant of gabapentin

Continue gabapentin

Patient has resources to pay for medicines

Yes

Begin Amitriptyline Protocol (pages 11-13) Or Nortriptyline Protocol (pages 14-16)

Or Desipramine Protocol (pages 17 & 18)

Stop gabapentin

2

No

Refer to page 5

Pain relieved

Continue Tricyclic

Pain relief not adequte

Stop Tricyclic

Refer to page 5

3

Concord Internal Medicine

Gabapentin (Neurontin) Protocol Rx 1 100-mg capsule Day 1-3: 1 tablet 2 times a day __________________________________ Day 4-6: 2 tablets 2 times a day _________________________________

Rx 2 600-mg tablets Day 7-9: ½ tablet 2 times a day _________________________________ Day 10-12: ½ tablet 3 times a day _______________________________ Day 13-15: 1 tablets 3 times a day _______________________________ Day 16-on: 1 tablets 4 times a day _______________________________ Day 23-28: Return for follow up visit

Follow up Visit _________________________________________________ • Titrate upwards until pain resolves, maximum dose is reached (or) side effects are too great. • If side effects too great, continue for 6 days the last dose tolerated and then try to increase

again. • If unable to tolerate maximum dose continue at last dose tolerated.

Side effects: drowsiness, lethargy, fatigue, depression

4


Gabapentin (Neurontin) Protocol Part 2

Rx 3 600-mg tablets Day 1-3: 1 tablet with each meal and

1 ½ tablets at bedtime ________________________ Day 4-6: 1 tablet with breakfast and with lunch,

1 ½ at supper and 1 ½ tablets at bedtime ________________ Day 7-9: 1 tablet with breakfast and 1 ½ with lunch, supper and at bedtime ______________________________ Day 10-on: 1 ½ tablets with each meal and at bedtime _______________

Follow up Visit _________________________________________________ • Titrate upwards until pain resolves, maximum dose is reached (or) side effects are too great. • If side effects too great, continue for 6 days the last dose tolerated and then try to increase

again. • If unable to tolerate maximum dose continue at last dose tolerated.

Side effects: drowsiness, lethargy, fatigue, depression

5

NoYes

Pregabalin protocol

Refer to page 8

Continue Medication

Continue Medication

Yes

Add or change to Pregabalin or Duloxetine (whichever was not on)

Intolerant of medication?

No Yes

Continue Medication

Pain controlled?

Continue Medication

Yes

Yes Pain

controlled?

Intolerant of medication?

No

Pain controlled?

No

No

Continue medication

Yes

Patient on a monamine oxidase inhibitor, SSRI, SNRI, tricyclic antidepressant

Refer to Page 6

No

Consider Amitriptyline Protocol (pages 12-14) or

Nortriptyline Protocol (pages 15-17) or

Desapramine Protocol (pages18-19)

Duloxetine protocol Refer to Page 7

or Pregabalin protocol

Refer to page 8

Pain relieved Pain not relieved

Refer to Page 6

`

Continue Medication

Yes No

Continue Medication

6

Consider referral to neurologist or

Switch patient to one of the medications (carbamazepine, lamotrigine, oxcarbazine) patient

is not currently on.

Continue Medication Refer to Neurologist or Pain Management

Pain controlled?

Continue Medication

Pain controlled?

Yes

Continue Medication


consider change to cvarbamazepine protocol (page 9) or

lamotrigine protocol (page 10) or

oxcarbazine protocol (page 11)

No

No

No Yes

Intolerant of Medication?

Intolerant of Medication

Yes

Pain Controlled?


Switch patient to whichever medication (carbanazepine, lamotrigine,

or oxcarbazepine)

patient has not been on.

Yes

No Yes

Intolerant of Medication

No


Add Tramadol 50-100 mg every 4-6 hours for pain (max 400 mg day, dose adjustment for elderly, renal and hepatic dysfunction). Consider use of

Tramadol and acetaminophen either separately or combined pill (Ultracet)

Continue Medication

Continue Medication

Yes

Pain controlled?

No

7


Duloxetine (Cymbalta) Protocol

Prior to prescribing, double check that patient not on another SSRI or SNRI. Not recommended if creatinine clearance < 30.

Rx 1 30 mg capsule Day 1-14 1 tablet daily Day 14-30 2 tablets daily Return for clinical follow up about one month and if controlled give RX 2

Follow up visit _____________________________________________________

RX 2 60 mg capsule, 1 tablet daily • Dose may be titrated up to 120 mg but doses > 60 mg have not been shown to be effective

and have increased side effects. Side effects: Nausea, somnolence, dizziness, and constipation.

Because nausea is so common, encourage patient to take on a full stomach.


8

Pregabalin (Lyrica) Protocol

See dose adjustment chart for renal insufficiency

Rx 1 50 mg capsule

Day 1 – 3, 1 tablet 2 x a day _____________________________________ Day 4 – 30, 1 tablets 3 x a day ___________________________________ Re-evaluate anytime at or after 14 days and titrate up with Rx 2 if inadequate clinical response. Rx 2 100 mg capsule

Day 1 – 3, 1 tablet 2 x a day _____________________________________ Day 4 – on, 1 tablets 3 x a day ___________________________________

Follow up visit _____________________________________________________ Dosing: Renal Impairment Pregabalin Renal Impairment Dosing

Clcr

(mL/minute)

Total Pregabalin Daily Dose For neuropathy

(mg/day)

Dosing

Frequency >60 150 300 2-3 divided doses

30-60 75 150 2-3 divided doses 15-30 25-50 75 1-2 divided doses <15 25 25-50 Single daily dose

Side effects: Dizziness, somnolence, edema, weight gain, blurred vision. Schedule V Substance – possibly habit forming. FDA Alert: May increase suicidal thinking!


9

Carbamazepine Protocol

Rx 1 100 mg

Day 1 – 14, 100 mg 2 x a day _________________________________ Day 14 – 30, 200 mg (2 tablets) 2 x a day _______________________ Rx 2 200 mg

Continue 200 mg 2 x a day.

Order monthly CBC (V58.69) for first 3 months to monitor given risk blood dyscrasias. Consider intermittent monitoring (q 6-12 months) thereafter.

Follow up visit _____________________________________________________ Adverse effects: Blood dyscrasias, skin rash (Stevens Johnson Syndrome has

been reported, nausea, and lethargy. FDA Alert: Suicidal thinking may be increased!

10


lamotrigine Protocol Rx 1 25 mg tablet

Day 1 – 5, 25 mg daily_____ _________________________________ Day 5 – 10, 25 mg 2 x daily __________________________________ Day 10 – 15, 50 mg (2 tablets) 2 x daily _________________________ Rx 2 100 mg tablet

Days 15 – on, 100 mg 2 x daily ________________________________

Follow up visit _____________________________________________________ Adverse effects: Stevens Johnson Syndrome has been reported, nausea, and

peripheral edema. FDA Alert: Suicidal thinking may be increased!

11


Oxcarbazepine (Trileptal) Protocol 600 mg tablet Day 1 – 7, ½ tablet each evening __________________________________ Day 8 – 14, ½ tablet twice a day ___________________________________ Day 15 – 21, ½ tablet each morning, 1 tablet each evening ______________ Day 22 – 28, 1 tablet each evening _________________________________

Follow up visit _____________________________________________________ • Titrate upwards until pain resolves, maximum dose is reached (or) side effects are too great. • If side effects too great, continue for 6 days the last dose tolerated and then try to increase

again. • If unable to tolerate maximum dose continue at last dose tolerated. Side effects: dizziness, drowsiness, fatigue, nausea, vomiting, difficulty with

walking, abdominal pain, tremor, heartburn, and confusion. Serum sodium weekly until patient on maintenance dose, then monthly x 3, then as clinically indicated. Note: Trileptal antagonized by carbamazepine, Dilantin and Lamotrigine. Trileptal may render birth control pills less effective.


12

Amitriptyline Protocol

10 mg tablet RX 1

Day 1 – 7, 1 tablet at bedtime _____________________________________ Day 8 – 14, 2 tablets at bedtime____________________________________ Day 15 – 21, 3 tablets at bedtime __________________________________ Day 22 – 28, 4 tablets at bedtime __________________________________ Day 22 – 35, 5 tablets at bedtime __________________________________


again. • If unable to tolerate maximum dose continue at last dose tolerated. Side effects: Dry mouth, drowsiness, dizziness, constipation, difficulty

urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)


13


Part 2

Take 1 50mg tablet at bedtime

PLUS 10 mg tablet

Day 1 – 7, 1 tablet at bedtime _____________________________________ Day 8 – 14, 2 tablets at bedtime____________________________________ Day 15 – 21, 3 tablets at bedtime __________________________________ Day 22 – 28, 4 tablets at bedtime __________________________________ Day 22 – 35, 5 tablets at bedtime __________________________________





14


Part 3


PLUS 10 mg tablet

Day 1 – 7, 1 tablet at bedtime _____________________________________ Day 8 – 14, 2 tablets at bedtime____________________________________ Day 15 – 21, 3 tablets at bedtime __________________________________ Day 22 – 28, 4 tablets at bedtime __________________________________ *Day 22 – 35, 5 tablets at bedtime _________________________________




*If patient is maintained on the maximum dose of Amitriptyline each evening, switch patient to a 150mg tablet.

15


Nortriptyline Protocol 10 mg tablet

Day 1 – 7, 1 capsule at bedtime ___________________________________ Day 8 – 14, 2 capsules at bedtime __________________________________ Day 15 – 21, 3 capsules at bedtime _________________________________ Day 22 – 28, 4 capsules at bedtime _________________________________ Day 22 – 35, 5 capsules at bedtime _________________________________




16


Nortriptyline Protocol Part 2

Take 1 50mg capsule at bedtime

PLUS

10 mg tablet

Day 1 – 7, 1 capsule at bedtime ___________________________________ Day 8 – 14, 2 capsules at bedtime__________________________________ Day 15 – 21, 3 capsules at bedtime ________________________________ Day 22 – 28, 4 capsules at bedtime ________________________________ Day 22 – 35, 5 capsules at bedtime _______________________________





17

Nortriptyline Protocol

Part 3

Take 2 50mg capsules at bedtime

PLUS 10 mg tablet

Day 1 – 7, 1 capsule at bedtime ___________________________________ Day 8 – 14, 2 capsules at bedtime__________________________________ Day 15 – 21, 3 capsules at bedtime_________________________________ Day 22 – 28, 4 capsules at bedtime_________________________________ *Day 22 – 35, 5 capsules at bedtime________________________________




*If patient is maintained on the maximum dose of 150mg per day of Nortriptyline each evening, switch the patient to two 75mg capsules.

18


Desipramine Protocol 25 mg tablet

Day 1 – 7, 1 tablet at bedtime ____________________________________ Day 8 – 14, 2 tablets at bedtime __________________________________ Day 15 – 21, 3 tablets at bedtime _________________________________ Day 22 – 28, 4 tablets at bedtime _________________________________




19


Desipramine Protocol Part 2


PLUS

25 mg tablet

Day 1 – 7, 1 tablet at bedtime ____________________________________ Day 8 – 14, 2 tablets at bedtime __________________________________ Day 15 – 21, 3 tablets at bedtime _________________________________ *Day 22 – 28, 4 tablets at bedtime ________________________________




*If patient is maintained on the maximum dose of 200mg per day of Desipramine each evening, switch the patient to two 100mg capsules.

CONCORD INTERNAL MEDICINE Peripheral …...Painful Peripheral Neuropathy Pathway Begin with...

Documents

Transcript of CONCORD INTERNAL MEDICINE Peripheral …...Painful Peripheral Neuropathy Pathway Begin with...