Copy of letter from the Canadian League Against Epilepsy

 

For Information Only, For Those on Frisium/clobazam.  Re: SHORTAGE SITUATION.  Letter posted online June 4, 2016

 

Canadian League Against Epilepsy I Ligue canadienne contre l’épilepsie

Clobazam Shortage?Suggestions for Management of Pediatric & Adult Patients with Epilepsy

June 4, 2016

There are shortages of clobazam, generic and brand name (Frisium). The situation has worsened during the past month reaching a crisis level.

Health Canada arranged a teleconference on June 3, 2016 to discuss the clobazam supply situation. Canadian League Against Epilepsy members participated in this meeting to convey the serious implications of a widespread clobazam shortage for patients with epilepsy.

Improvements in the clobazam supply are expected by late June to early July. Apotex Inc., the major supplier of clobazam in Canada, will be returning to regular supply levels. Several batches of Apo-Clobazam are expected to be released to wholesalers during the last two weeks of June.

Also, there should be additional Frisium (brand name clobazam) in the coming weeks from Lundbeck LLC.

There may continue to be some serious supply problems during the next three to four weeks. It is hoped that efforts will be made to identify sources of clobazam in the drug supply chain in order to protect patients.

Clobazam is a Level 1 Critical Drug for patients with epilepsy, according to the Canadian Pharmacists Association classification.

Prescribers asked to switch a patient from clobazam to an alternate drug, due to the shortage, should first request that the patient’s pharmacist double check all supply avenues to obtain either the same formulation or an interchangeable form (generic or brand) of clobazam. In addition to regular wholesalers, pharmacists can explore if supply is available from other wholesalers, other pharmacies or directly from one of the manufacturers.

All supply avenues should be exhausted before a patient who has been stabilized on clobazam is switched to an alternate drug. A decision must be made more quickly if the patient has minimal supply remaining to prevent interruption in therapy.

Clobazam is a 1,5-benzodiazepine with a long duration of action and has been marketed as an antiseizure drug in Canada for nearly 20 years. This medication is commonly used to treat epilepsy.

Interruption or sudden discontinuation of antiseizure drug therapy can cause a loss of seizure control, or worsening of a patient’s condition, with significant short- and long-term implications for patient safety, independence and quality of life. Breakthrough seizures can have potentially fatal consequences.ii

There are additional concerns related to this particular drug shortage. Sudden discontinuation of clobazam can cause benzodiazepine withdrawal syndrome.iii Abrupt discontinuation of clobazam may exacerbate seizures and cause other benzodiazepine withdrawal symptoms.iv Abrupt withdrawal of clobazam can also put patients at risk of life-threatening status epilepticus.v

Suggestions for Patient Management During the Clobazam Shortage

Patients who require de novo treatment?In patients who require de novo treatment with an antiseizure medication during the clobazam shortage, physicians should consider whether an alternative medication could be used at least initially.

Patients currently taking clobazam?If all supply avenues have been exhausted and there is no clobazam available, an alternate medication should be substituted until clobazam can be resupplied to the patient.

The following rationale for the selection of clonazepam as an alternative medication to clobazam during a drug shortage is from a document written by J.C. Martin del Campo, MD, FRCP and Jorge G. Burneo, MD, MSPH in 2013vi:

From the benzodiazepine group, only two other drugs have been found useful for the chronic management of seizure disorders: nitrazepam and clonazepam.

While there is no published evidence of efficacy under the circumstances, the most reasonable substitute for clobazam is clonazepam.

It is not known if this will be efficacious in all patients or if the recommended equivalent will result in a decompensation of the seizure disorder, but it is reasonable to surmise that it may prevent the development of a withdrawal state resulting in status epilepticus. Any given dosage will need to be carefully monitored by the prescribing physician and adjustments made where necessary.

While making these recommendations, it is hoped that the health authorities and pharmaceutical companies will protect the public by urgently implementing a strategic plan that will prevent such shortages from occurring. It is imperative to be reminded of the potentially fatal consequences of breakthrough seizures.vii

Reproduced with permission from del Campo and Burneo.

Recommendations for Therapeutic Substitution of Clonazepam for Clobazam

Clonazepam (brand name Rivotril) is a 1,4-benzodiazepine. This medication is available as an oral tablet in 0.25 mg, 0.5 mg, 1 mg and 2 mg formulations.

ClonazePAM and cloBAZam have similar lipophilicity and protein binding therefore likely very similar CNS penetration.

Clonazepam is more potent than clobazam. It is at least 10X more potent than clobazam if not ?20X, therefore, 1 mg of clonazePAM may be similar in potency to 10 mg of cloBAZam but could be as potent as 20 mg of cloBAZam.viii

Following conversion to clonazepam, some dose titration may be required to achieve the desired therapeutic effect. Clinical judgement is necessary to determine the optimum dose for each patient.

Patients should be carefully monitored for changes in seizure frequency, as well as the emergence of any adverse effects (excessive sedation, ataxia, increased difficulty handling secretions, worsening liver function) following the switch. ClonazePAM causes more sedation than equipotent doses of cloBAZam and tolerance may be more likely to develop to its antiseizure activity.

The excipients and non-medicinal ingredients between formulations may be different so caution should be exercised in patients with known hypersensitivity to excipient. These, along with any differences in adverse event profiles, can be verified in the appropriate Product Monographs and labels. The Product Monographs are available from the Health Canada Drug Product Database.ix

ADULTS? Initiate at 0.5 mg clonazePAM for every 10 mg clobazam (1:20)x; in 3-5 days, in the absence of adverse effects, increase to 1 mg clonazePAM for every 10 mg clobazam if required, to a maximum of 3 mg clonazepam/day.

Consider initiating clonazepam with a simultaneous gradual tapering of cloBAZam by 5-10 mg/week if supply allows.

PEDIATRICS?Initiate at 0.5 mg clonazePAM for every 10 mg clobazam (1:20); direct substitution can be made, tapering of clobazam is not mandatory. Dose titration, up or down, should be based on patient response.

Dose increases in pediatric patients, if required, are typically 0.25-0.5 mg/day every 5-7 days to a maximum of 0.1 mg/kg/day (or 0.2mg/kg/day for patients on enzyme-inducing drugs)xi

SENIORS, PATIENTS WITH LIVER DISEASE OR PATIENTS ON MEDICATIONS THAT INHIBIT P450-3A4 Initiate clonazepam at lower dosages in the elderly, in patients with liver disease, or in patients who are currently on medications which inhibit cytochrome P450-3A4.

 

Drug Metabolism and Pharmacokinetics

CloBAZam and clonazePAM are primarily metabolized by CYP 3A4. CloBAZam’s active metabolite, N- desmethylclobazam, is primarily metabolized by CYP 2C19. When substituting clonazePAM for cloBAZam, a thorough drug interaction assessment should be done taking these metabolic paths into consideration.

Information and Support for Practitioners and Patients

Should practitioners have reservations or concerns about the clinical management of their patients with epilepsy during this shortage, they should consult their nearest neurologist with epilepsy expertise or comprehensive epilepsy centre.

Patients and caregivers can contact their local Canadian Epilepsy Alliance agency for information and support by calling 1-866-EPILEPSY (1-866-374-5377).

i “Level 1 Critical Drug: Drug therapy for disease is essential and cannot be interrupted for even one dose or one day.” From: Canadian Pharmacists Association (2010), Drug Shortages: A Guide for Assessment and Patient Management www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/DrugShortagesGuide.pdf?ii Steinhoff, B.J., et al. (2009) Substitution of anticonvulsant drugs. Ther Clin Risk Manag., 5, 449–457. www.ncbi.nlm.nih.gov/pmc/articles/PMC2701486/pdf/tcrm-5-449.pdf

iii Frisium Product Monograph (2015) iv ibid

vii Steinhoff, B.J., et al. (2009) Substitution of anticonvulsant drugs. Ther Clin Risk Manag., 5, 449–457.?viii Sankar, R. et al. (2014) Clinical considerations in transitioning patients with epilepsy from clonazepam to clobazam: a case series. J. Med. Case Rep., 8: 429. www.ncbi.nlm.nih.gov/pmc/articles/PMC4302143/pdf/13256_2014_Article_3028.pdf?ix Product monographs are available for download from the Health Canada Drug Product Database: www.hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php?x Benzodiazepine equivalence table http://www.benzo.org.uk/bzequiv.htm (accessed May 16, 2016)?xi Farrell, K. and Michoulas, A. (2008) Benzodiazepines. In J.M. Pellock et al. (Ed), Pediatric Epilepsy: Diagnosis and therapy, 3rd Edition. Demos Medical Publishing, New York, page 559.?xii Brodie, M.J., et al. (2016) Clobazam and clonazepam use in epilepsy: Results from a UK database incident user cohort study. Epilepsy Research 123, 68-74.?xiii ibid?xiv Comparison of benzodiazepines http://www.vhpharmsci.com/vhformulary/tools/benzodiazepines- comparison.htm (accessed May 18, 2016)

Drug Benzodiazepine Group Active Metabolite Half-life of parent (hrs) Half life of active metabolite (hrs)
cloBAZam 1,5-benzodiazepine N-desmethylclobazam 30xii 80xiii
clonazePAM 1,4-benzodiazepine   18-39xiv

v Engel, J. (2013). Seizures and Epilepsy, 2nd Edition. Oxford University Press, New York, page 557.?vi Del Campo, M. and Burneo, J. (2013). Therapeutic alternative to clobazam: Medical recommendation for adults with epilepsy. Retrieved from Epilepsy Ontario website: epilepsyontario.org/wp- content/uploads/2014/01/Clobazam_Therapeutic-alternative-for-adults_Jan2013.pdf

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In Case You’ve Just Thrown Out All Of Your Supplements.
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Just in case you are being drawn in by the overwhelming attempt to draw you away from anything that is labeled as a supplement, be weary of one red flag: a claim that “there are no studies showing any effectiveness”. No studies. Not even one. Not a single, solitary inkling of any positive outcome in any way, from any dose or for any medical benefit whatsoever. And this is for a multitude of molecules and a whole list of medical conditions. Imagine the possible permutations. How many combinations of supplements and medical issues are possible? It boggles the mind. And not even one slight benefit from any one of these naturally occurring entities – regardless of what we are eating. The one exception is when a Physician diagnoses a deficiency based on the pooled data of all sick and well patients’ blood levels.  It almost seems impossible to believe.

Equally difficult to believe is the incredible effort that is out there to make people believe this. In social media it is hard to estimate how little of one’s mind is actually firing when we read article after article. What part of the brain that deals with reasoning and logic is getting numbed with this type of activity. Who knows? In any case there are many that take advantage of this and take an unsuspecting reader by the hand, down the garden path and have them walk away with an opinion that they normally wouldn’t.   The same authors, over and over again pen an “evidence based” look at supplements. These articles hand-pick studies, many of them well done, to pad their argument. They may claim that you are falling to the charlatans that are looking to grab your money for the promise that you will live longer. Is it not strange that we have list of people that are always are for or always against supplements? Beyond, rickets, scurvy and beriberi we should be ok. With the exception of B12, Iron, Folic acid, Calcium and maybe thiamin, we have found there isn’t much use in supplementing beyond the normal standard North American Diet (which we all know is stellar to say the least).  Our staggering increase in obesity rates suggest this way of eating has unhealthy issues.   Consistently this is done without even a small open window of the opposing side having any effect at all.

Don’t get me wrong. There are those who exist at the other end of the spectrum as well. The ultra gurus that give supplements a bad name by overselling any supplement to anyone that will buy one. Neither side is being truthful, or helpful to the overall health of the reader. Our scientific method has proven over hundreds of years to be a good system of separating chance from true cause and effect. Although not perfect, it works like a puzzle in that the more pieces we develop from well designed and executed studies, the better an overall picture we get. Some pieces frustrate us because they seem to go against previous pieces. We try to explain everything based on one piece, or a few recently found pieces. This only leads to frustration as we claim to be experts on the more recent studies that seem to completely discount anything earlier. Some find it hard to try and explain studies that don’t gel with their opinion. Rather than trying to explain how it is part of the whole picture, they discount it as a bad study. To further cloud the argument, there are statements of supplements that don’t have what they claim on the label, or contain ingredients that shouldn’t be in the supplement. There are issues of hospitalization, side effects and interactions with supplements – all true, but take away from the argument of the actual supplement doing what it is claimed to do.

Take for example the case of the supplement known as Omega-3. As of late the “unbiased” forum has been quite active in trying to deter anyone from trying it for whatever reason. Well written articles too. And they aren’t really lying for the most part. Well for the most part. Studies are out there that claim Omega 3 isn’t good for heart attack prevention, for cholesterol, but use painfully low levels of omega 3 and claim that omega 3 is useless when no effect is found. This effect is compounded when incorrect titles are put on the study and carried on in the media.

So, to even out the argument, the studies that didn’t exist in these one sided, unbiased, “stay away from your pharmacist trying to sell something they are recommending so it must be bad” stories include these:

 

Omega 3 and cardiac sudden death

Cardiovascular risk and the omega-3 index. von Schacky C, Harris WS. J Cardiovasc Med (Hagerstown) 2007;8 Suppl 1:S46-9.

 

Blood levels of long-chain n-3 fatty acids and the risk of sudden death. Albert CM et al. N Engl J Med 2002;346:1113-1118.

Dietary intake and cell membrane levels of long-chain n-3 polyunsaturated fatty?acids and the risk of primary cardiac arrest. Siscovick DS et al. JAMA 1995;274:1363

 

Omega 3 and cardiovascular disease

http://www.medscape.com/viewarticle/764574

 

Omega 3 and pain relief, inflammation

http://www.ncbi.nlm.nih.gov/pubmed/16531187

http://www.ncbi.nlm.nih.gov/pubmed/9028717

http://advances.nutrition.org/content/2/4/304.full

http://www.ncbi.nlm.nih.gov/pubmed/18362100

http://www.ncbi.nlm.nih.gov/pubmed/16531187

 

Omega 3 and autoimmune

http://www.ncbi.nlm.nih.gov/pubmed/12480795

 

Omega 3 and Child behavior/Spelling in school

.http://pediatrics.aappublications.org/content/115/5/1360

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0043909

http://www.medscape.com/viewarticle/808285#vp_1

.  http://www.ncbi.nlm.nih.gov/pubmed/23056476

 

 

Omega 3 and insulin resistance

http://www.nature.com/srep/2014/141021/srep06697/full/srep06697.html

http://www.ncbi.nlm.nih.gov/pubmed/3320694

http://www.ncbi.nlm.nih.gov/pubmed/18348080

 

Omega 3 and dyslipidemia

 http://www.medscape.com/viewarticle/764574_3

  http://www.medscape.com/viewarticle/789642

 http://www.medscape.com/viewarticle/764574_3

http://www.ncbi.nlm.nih.gov/pubmed/19356403

http://www.ncbi.nlm.nih.gov/pubmed/21684546

 

 Omega 3 and anticoagulant and anti arrhythmic

 http://www.medscape.com/viewarticle/789359

 

 

So keep in mind that if we knew all there was to know about just this one supplement, there wouldn’t be a need for any further studies on it and we would all be experts on it. The truth is somewhere in between those that claim supplements are the thing to replace all conventional medications and everyone needs them all , and those that claim supplements are completely useless. To claim that it is just iron, B12, Calcium, and folic acid are the only necessary supplements makes very little sense given the vast knowledge we have from years of scientific study.

 

Graham MacKenzie, Ph.C.

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New Senate Proposed Sugary Beverage Tax – The Real Benefit Isn’t Lower Obesity Rates
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backgroundThe month of March ushered in news of a new report entitled “Obesity in Canada”. Submitted by the Senate, this report was a 21 recommendation paper to try and constructively address the growing concern of why Canadians are following its Southern neighbors in growing rates of obesity in both children and adults. In fact there are is a doubling in obesity in adults since 1980 and children’s obesity rates in this country have tripled in that time. This report was a breath of fresh air from a government group that many today look at with question of why they are even there.

As a Pharmacy owner that discontinued sale of such products in September of 2014, this story caught my eye. Anything having something to do with sugary beverages is a hot topic with the media, as I abruptly found out that day a year and a half ago. Even a small pharmacy in the middle of nowhere can make the national and international news by making “such a bold and forward thinking move” (as it was described) as stopping the sale of everything from pop, juice, vitamin water, sports drinks and chocolate milk.

Any talk of manipulating the sale of a staple in the Canadian diet will bring about cries of a “Nanny State move”. So when news hit that one of the recommendations from the Senate’s report was a proposed tax on such drinks, the naysayers came out of the woodwork, and along with them, the defenders of the plan. One of the first to press against the idea was Jim Goetz, the president of the Canadian Beverage Association who attempted to educate us in a biased way with stories of how this has been tried in other parts of the world and didn’t work, had no effect on obesity and resulted in lost jobs and increased grocery expenditures. Mr. Goetz is a name I learned back when I stopped selling these beverages and saw an article in rebuttal to this type of move. When I read of crazy claims that increased calorie intake had nothing to do with obesity, it really opened my eyes to the war that goes on in this category.

Granted there is no shortage of stories where an increase in tax on a target food group seemed to be a dud with respect to changes in obesity, even when the calorie intake did seem to drop. Denmark, Mexico, the United States, Finland, France, Hungary all are examples of stories where a tax was implemented with results that vary depending on who tells the story. In fact during a recent CBC Radio interview on the Senate report I gave recently, I was pressed on the success (or lack of) in such programs. I was quite persistent though on the complete irrelevance of the obesity outcome but rather we should focus on the fact that we need to pay for the adverse health issues that arise from the obesity that we know these beverages cause.

When I cross from Dartmouth to Halifax on either bridge, I expect to pay a toll. It doesn’t really cause me to take the long way around through Bedford, I pay the toll and drive over the bridge. I do it because I realize the upkeep of the bridge has to happen somehow and if I don’t pay it through tolls, I’ll sure as heck going to end up paying it some other way. It just makes sense for users to pay for that. When I buy tires for my car, I pay a fee that is to be used for the recycling of that tire at its end of life. You just do it because something has to happen to that tire when you’re done with it and that costs money to do.

If you agree that extra calorie intake results in obesity, then what is it that drains the healthcare budget of a country so quick when its population becomes more obese? Children with obesity are more likely to suffer from type 2 diabetes, hypertension and asthma. Adults with obesity have a higher incidence of depression, anxiety, heart disease and diabetes and also are more likely to be absent from work, pursue lower income jobs and earn lower overall wages (and in doing so pay less tax). Last year in the U.S., health care costs as a result of obesity reached $300 billion annually. A simple consideration in mathematics will show how this cost could be somewhat offset by a sugary beverage tax. Even though there are many reasons a nation becomes overweight, sugary beverages are one of them and you can consider it a user fee with that tax.

Lots of other great ideas came from the report, like an overhaul of the Canada Food Guide – without involvement from the food industry and one of my favorite recommendations, stricter controls on advertising unhealthy food and drinks for kids. Well done Canadian Senate!

Graham MacKenzie Ph.C.

IMG_2313[2] copyStone’s Pharmasave

Baddeck, Nova Scotia

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Your Pharmacy is Most Likely an Alternative, Complimentary, Off Label, Patient Centred One
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  Most Pharmacists rely on the foundation that their “evidence-based” mantra is being followed. A simple Google search shows us that: “Alternative medicine is any practice that is put forward as having the healing effects of medicine, but does not … Continue reading

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16 Things the Profession of Pharmacy Taught Me
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 There’s a big difference between the promising world of Pharmacy School and the real world of being there. A few things that stand out in no particular order after over 20 years would be:  -There are people out there for … Continue reading

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Have we allowed Medical Insurance Plans to Have too Much Control of our Health?
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   Who is it that really makes the final call on what your treatment is for any of your medical conditions? Most would say their doctor. As a pharmacist however I see something different. It is common to see a … Continue reading

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The Value of a Local Independent Pharmacy
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The Value of a local Independent Pharmacy

It’s difficult to find anything for free these days.   I see bills for such things as faxing to a local number, photocopying, corking fee to open wine bottles at a function, cutting up a cake, supplying year end receipts, filling out health insurance forms, consultations, supplying information, It is also difficult to have a donation request responded to without a waiting period for most people.

So what does a pharmacy do differently? (especially a small town or independent pharmacy). Well we give volumes of donations to local causes after weekly and sometimes daily requests. Quite often we give you your year end tax receipts free, call your doctor for free, fax your form to your drug plan (after we have filled it out for you), talk to you on the phone for 10-15 minutes at a time or sit down for even longer about your health concerns for free.   In my area I am the only pharmacy and often a temporary charge medications if a patient doesn’t have the money, I do public speaking for free for anyone who asks. I do glucose and cholesterol tests for free, make deliveries daily to our nursing home and supply free INR tests to their residents as needed, and OTC counselling off and on all day long. Most people assume many of these things are done readily for free by their local pharmacy. Other services eek their way out as well, like a 45 minute grocery store tour to help people eat better http://www.stonespharmasave.com

While it is true that pharmacies charge a dispensing fee for filling a prescription, it is that one fee that fuels most of these other daily contributions and tasks.   Keep in mind that some pharmacies charge for some of these services and some do not. As well, lots of businesses do stuff for free. Should I be charging for all of these services? Some would say yes. The local independent pharmacy that sticks out its neck and serves the small community that bigger name pharmacies don’t go is invaluable to the community in more ways than just a place to fill prescriptions.

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Off label use of medications – cherry picking at its best
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IMG_2313[2]I had a conversation with our local palliative care and pain clinic doctor the other day. As a disclaimer, this physician is open to treating patients with the safety of the patient first in mind and he also has what I refer to as an “open mind” when it comes to doing whatever we can to alleviate pain and suffering. A lot of the time it involves using medications and therapies that most physicians would prescribe. It also involves therapies that are safe and effective but are shunned by other physicians either because of lack of knowledge or experience with them or because they claim it is an off label use or one that lacks either a firm recommendation from a governing body or has not been recommended at a recent conference they attended.

Off label prescription writing is certainly not a stranger to my daily dispensing of drugs. Some reviews put this practice as high as 10% of prescriptions written in Canada. A May 2012 MacLean’s article discusses this as a major issue and a huge gamble for the physicians writing these prescriptions. As a pharmacists, I can assure you that this practice is the norm and for the most part doesn’t land people in the hospital any more often than officially approved writing of any other prescription medication such as NSAIDS, narcotics, blood pressure or heart meds, or antibiotics, to name a few. There are hundreds of examples of off label uses of drugs now being written for. A few common ones listed by the Lexicomp Facts and Comparisons Off Label are:

 

ASA for high risk coronary artery disease

Clonidine for hot flashes

Erythromycin for acne vulgaris

Folic acid for neural tube defects

Gabapentin for diabetic neuropathy

Nifedipine topical for anal fissures

Trazodone for insomnia in the elderly

Amitriptyline (oral or topical) for neuropathic pain

Childhood and adolescent uses of many medications

 

Note the use of the amitriptyline topically. Topical compounds are notoriously listed here although there are studies showing they work for various types of pain when used correctly at the right strength. Granted many of these studies are small but many are well designed and like I always say, nothing beats the experience of the first patient a physician tries and sees the topical preparation working and the lack of side effects compared to oral medications is an added bonus.

Most consider topical pain therapy to be limited to capsaicin, lidocaine and camphor menthol combinations.  There is an entire universe out there of other ingredients used in these preparations. And for those who like a few references here you go.

Dubinsky RM, Kabbani H, El-Chami Z, Boutwell C, Ali H; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004;63(6):959-965.[PubMed 15452284]

Ho KY, Huh BK, White WD, Yeh CC, Miller EJ. Topical amitriptyline versus lidocaine in the treatment of neuropathic pain. Clin J Pain. 2008;24(1):51-55.[PubMed 18180637]

Lynch ME, Clark AJ, Sawynok J, Sullivan MJ. Topical 2% amitriptyline and 1% ketamine in neuropathic pain syndromes: a randomized, double-blind, placebo-controlled trial. Anesthesiology. 2005;103(1):140-146.[PubMed 15983466]

Lockhart E. Topical combination of amitriptyline and ketamine for post herpetic neuralgia. Poster presented at: American Pain Society Annual Meeting; May 6-9, 2004; Vancouver, BC. http://www.ampainsoc.org/db2/abstract/view?poster_id=2185#893. Accessed November 4, 2008.

 

-Lexicomp

 

Now a common complaint is that I supply studies that cherry pick what I am trying to prove, although I assume that whomever is asking has plenty of studies to favour something against my side. The point is, when you know something works, and it’s safe, you tend to care more about potential patients and less about converting non believers. Topical pain relief is just one of those “alternative” therapies. Many would consider off label use to be alternative therapy by definition. If alternative therapy is something that wanders past a monograph or official indication, then many practice alternative medicine. If that therapy is “recommended” by a medical group then for most it becomes accepted therapy and therefore not alternative. Although this may make them more comfortable with prescribing choices, alternative therapy’s definition is one that changes based on the one defining it.

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Zinc levels and Erectile Dysfunction and Low Libido
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With the erectile dysfunction (ED) market expected to reach 3.4 billion dollars (USD) by 2019, this is a lucrative area to invest in, and not much grabs the attention of a guy watching a commercial during a Monday night football … Continue reading

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Treating Pain Without Oral Systemic Side Effects

You may be the last person to side with even listen to something that isn’t taught in Med School or Pharmacy School or in Nursing School or perhaps you are one to be weary about snake oil or getting hoodwinked … Continue reading

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