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Thank you for entrusting in the compounding services at MD Custom Rx to help meet the unique medication needs of your patients. We are excited to share with you our monthly newsletter and look forward to continuing to be your medication problem solvers. Please don't ever hesitate to let us know how we can be of further assistance to you and your practice.
Sincerely,
John, Dan and Monica |
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Ketamine in Pain Management
Ketamine is a noncompetitive antagonist of N-methyl-d-aspartate receptor. It has been widely used in anesthesia and pain management. Ketamine has been administered via the intravenous, intramuscular, subcutaneous, oral, rectal, topical, intranasal, sublingual, epidural, and caudal routes. Ketamine improves postoperative and posttrauma pain scores and reduces opioid consumption. It has special indication for patients with opioid tolerance, acute hyperalgesia, and neuropathic pain. It also has a role in the management of chronic pain including both cancer and noncancer pain.
Our compounding pharmacists frequently combine ketamine with other medications that have different mechanisms of action to treat pain that has been refractory to traditional, commercially available drugs.
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Topical Amitriptyline-Ketamine for Treatment of Refractory Brachioradial Pruritus
Brachioradial pruritus is a neuropathic condition that is characterized by unilateral or bilateral upper extremity itching. A case report was published of a 41 yo male patient with brachioradial pruritus at the Mayo Clinic. His severe symptoms were refractory to multiple treatments and his disease had progressed to the point where he was having symptoms almost continuously. The patient was prescribed amitriptyline HCl 1% with ketamine HCl 0.5% in a vanishing cream base to be applied to the affected area 2 to 3 times per day. "He reported complete relief with this topical agent and continued to use it over the next 4 years. At his last check-up, he reported that he still was using topical amitriptyline-ketamine at least once daily, and it continued to give him complete symptomatic relief."
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Topical Amitriptyline-Ketamine for Treatment of Rectal, Genital, and Perineal Pain and Discomfort
Pain in the rectal, genital, and perineal area can evolve into potentially life-altering chronic pain conditions, which are therapeutically challenging because both interventional and drug therapies often are ineffective. Compounded topical amitriptyline-ketamine is used for neuropathic pain in various disorders, including peripheral neuropathies, neurovascular disorders, and postinfectious and postoperative neuralgias. The two medications in this compounded gel are hypothesized to act synergistically through different pathways to dull transmission of unpleasant stimuli.
Poterucha et al. of the Mayo Medical School and Mayo Clinic conducted a retrospective review of medical records to determine if pelvic pain can be treated effectively with compounded topical amitriptyline-ketamine. They identified all patients treated with topical amitriptyline-ketamine from 2004-2011. Medical records were evaluated to determine the diagnosis for which the medication was prescribed. Treatment efficacy and any adverse effects were recorded. Of the 1,068 patients who received amitriptyline-ketamine, 13 had the medication prescribed for genital, rectal, or perineal pain and had medication efficacy recorded. Of these 13 patients, one (8%) had complete relief, 6 (46%) had substantial relief, 4 (31%) had some relief, and 2 (15%) had no response. One patient reported occasional irritation while using topical amitriptyline-ketamine with lidocaine; no other patients reported local or systemic adverse effects.
Conclusion: Topical amitriptyline-ketamine provided a high rate of pain relief with a low adverse-effect burden in patients with pelvic pain. This topical medication could offer an effective, noninvasive, nonopioid therapy for pain in the rectum, perineum, and genitals.
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Topical Amitriptyline, Ketamine, and Lidocaine to Treat Neuropathic Pain Caused by Radiation Skin Reaction
During radical radiation therapy, the basal layer of the epidermis is damaged as early as 10-14 days after dosing and is characterized by a reactive pink hue without epidermal changes. Often, pruritus or pain is present. After 4-5 weeks of radiation therapy, loss of epidermis results in moist desquamation and considerable pain. The incidence of moist desquamation can be as high as 21-38% in patients with breast cancer, depending on the type of radiotherapy. Patients with anal canal tumors and some types of gynecologic tumors undergoing radiation and chemotherapy experience close to a 100% incidence of dermatitis. Often, these painful skin reactions have neuropathic qualities, such as deep and intense burning, and do not respond to standard therapies but require multiple agents for optimal pain relief. "Modulation of these peripheral processes with localized topical agents may be appropriate for relief of pain."
A pilot study evaluated the effect of topical amitriptyline 2%, ketamine 1%, and lidocaine 5% (AKL) on alleviation of neuropathic pain from radiation dermatitis to determine the feasibility of a randomized trial. Eligible subjects had radiation dermatitis with dry or moist desquamation with neuropathic pain and were intolerant or allergic to standard intervention. AKL was applied to painful sites three times a day daily until 2 weeks post-radiotherapy. Subjects were monitored every 2-5 days during radiotherapy and at 2 and 6 weeks after completion of radiotherapy. The University of Washington Neuropathic Pain Scale was used to grade the neuropathic pain before and after use of the interventional gel. Compliance was assessed by asking subjects at each visit how frequently they were using the interventional gel.
Over a 14-month period, 16 subjects met eligibility criteria. Eighty-two percent of subjects used the AKL as directed. Five subjects (32%) reported fatigue, and three subjects (19%) reported site irritation from the interventional gel. AKL was shown to significantly reduce pain intensity, sharpness, burning, sensitivity, and itchiness on a short-term basis (i.e., between pre-treatment and 30 min post-treatment). Topical amitriptyline/ketamine/lidocaine was shown to significantly reduce burning levels on a long-term basis (i.e., between pre-treatment and 2 weeks post-treatment).
Conclusion: AKL was a safe intervention to use with minimal toxicity and good compliance. It significantly reduced several measures of neuropathic pain associated with radiation dermatitis.
Contact our compounding pharmacy to discuss customized topical and transdermal pain medications to meet each patient's specific needs.
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