concord internal medicine peripheral …...painful peripheral neuropathy pathway begin with...
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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 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 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
Concord Internal Medicine
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 referral to neurologist or
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?
Consider referral to neurologist or
Switch patient to whichever medication (carbanazepine, lamotrigine,
or oxcarbazepine)
patient has not been on.
Yes
No Yes
Intolerant of Medication
No
Consider referral to neurologist or
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
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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.
Concord Internal Medicine
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!
Concord Internal Medicine
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
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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!
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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.
Concord Internal Medicine
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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 __________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
Concord Internal Medicine
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Amitriptyline Protocol
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 __________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
Concord Internal Medicine
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Amitriptyline Protocol
Part 3
Take 1 100mg 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 _________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
*If patient is maintained on the maximum dose of Amitriptyline each evening, switch patient to a 150mg tablet.
15
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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 _________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
16
Concord Internal Medicine
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 _______________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
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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________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
*If patient is maintained on the maximum dose of 150mg per day of Nortriptyline each evening, switch the patient to two 75mg capsules.
18
Concord Internal Medicine
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 _________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
19
Concord Internal Medicine
Desipramine Protocol Part 2
Take 1 100mg tablet at bedtime
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 ________________________________
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: Dry mouth, drowsiness, dizziness, constipation, difficulty
urinating, blurred vision, confusion, disorientation, increased appetite, fast heart rate (> 100 beats per minute)
*If patient is maintained on the maximum dose of 200mg per day of Desipramine each evening, switch the patient to two 100mg capsules.