A presentation I gave during an internship/Advanced Pharmacy Practice Experience (APPE) in medicine at a hospital.

1. Paul Pasco, PharmD
Candidate
ppasco@uthsc.edu
UTHSC College of Pharmacy
Thursday, June 24, 2021
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2. Abbreviations
2
BID = twice daily
BP = blood pressure
GABA = gamma aminobuytric acid
HR = heart rate
O2 = oxygen
PI = package insert
PO = by mouth
qHS = at bedtime
RR = respiratory rate
SCI = spinal cord injury
SNRIs = serotonin-norepinephrine
reuptake inhibitors
TID = three times daily
TCAs = tricyclic antidepressants

3. Objectives
 Briefly review the pathophysiology of neuropathic pain in SCIs.
 Provide recommendations on performing a nursing assessment of pain.
 List the preferred medications for neuropathic pain in SCIs.
 Describe the adverse effects of these medications.
 Describe monitoring parameters of these medications.
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4. Pathophysiology
 SCIs → neuropathic pain (also called neurogenic)
 Abnormal communication between brain and nerves
 Can happen in areas above or below the injury
 Usually chronic
 Burning, stabbing, tingling, “pins and needles”
 Qualities vary greatly between patients
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5. Pain Assessment
 Location
 R vs. L
 Intensity
 Objective scale (1-10)
 Duration
 1 week, 1 month, 1 year
 Description
 Burning, shooting, stabbing
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6. Pain Assessment (cont.)
 Speaking to patient
 “Tell me about your pain.” (open-ended)
 “Is your pain a 10 today?” (closed-ended)
 Methods for assessing pain:
 Patient-reported
 Altered mental status
 Truthfulness
 Behavioral
 May not be congruent with report
 Physiological
 Increased BP, HR
 Increased/decreased/change in pattern of RR
 Decreased O2 sat
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7. Treatment - SNRIs
BRAND GENERIC DOSE MONITORING
Cymbalta® Duloxetine
• Start at 30 mg PO daily.
• Max daily dose = 60 mg
• Increased bleeding with blood thinners, aspirin,
related drugs
• Headache, nausea
• Increased BP
• Low blood sodium
• Do *NOT* open capsules
• Take with or without food
• Dose adjustment in kidney disease
Effexor XR®
Venlafaxine
extended-
release
• Start at 37.5 mg PO
daily.
• Max daily dose = 225
mg
• Take with food
• Capsules *CAN* be opened and sprinkled on
soft food
• Otherwise, same as above
3. Prescribing Information - EFFEXOR XR® (Venlafaxine Extended-Release) Capsules. Wyeth Pharmaceuticals (a subsidiary of Pfizer Inc.); 2017:1-40. Accessed June 17,
2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020699s107lbl.pdf
4. Prescribing Information - Cymbalta® (Duloxetine Hydrochloride) Capsules. Eli Lilly and Company; 2010:1-33. Accessed June 17,
2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf
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8. Treatment – TCAs
BRAND GENERIC DOSE MONITORING
Aventyl®,
Pamelor®
Nortriptyline • Start at 10–25 mg, PO, qHS
• Max daily dose = 150 mg
• Sedation
• EKG changes
• Confusion (esp. in elderly)
• Dry mouth, urine/fecal retention
• Sweating, restlessness, muscle rigidity when
used with some other drugs for mood (medical
emergency)
Elavil® Amitryptiline
• Start at 10–25 mg, PO, qHS
• Max daily dose = 150 mg
Same as above
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7. Product Monograph - Aventyl (Nortriptyline Hydrochloride). AA Pharma; 2014:1-17. Accessed June 23, 2021. https://www.aapharma.ca/downloads/en/PIL/Aventyl_PM.pdf​
8. Prescribing Information - Amitriptyline. Published September 15, 2017. Accessed June 23, 2021. https://pdf.hres.ca/dpd_pm/00041275.PDF

9. Treatment - Gabapentinoids/GABA
Analogues
BRAND GENERIC DOSE MONITORING
Neurontin® Gabapentin
• Slow increase up to 600 mg PO TID.
• Max daily dose = 3600 mg
• Not interchangeable with other
formulations
• Dose adjustment in kidney disease
Gralise®
Gabapentin,
once-daily
• Start at 300 mg, PO, with evening
meal
• Increase in 300 mg increments to an
1800 mg dose over 15 days (see PI)
• Not interchangeable
with other formulations
• Do not crush, cut, or chew
• Take with food (fatty meal is ideal)
• Dose adjustment in kidney disease
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5. Prescribing Information - Gralise® (Gabapentin) Tablets. Gralise.com. Published April 2020. Accessed June 17, 2021. https://www.gralise.com/pdfs/gralise-prescribing-information.pdf
9. Prescribing Information - Neurontin (Gabapentin). Pfizer; 2017:1-37. Accessed June 23, 2021.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020235s064_020882s047_021129s046lbl.pdf

10. Treatment -
Gabapentinoids/GABA Analogues (cont.)
BRAND GENERIC DOSE MONITORING
Horizant®
Gabapentin enacarbil
(extended release
tablets)
• Start at 600 mg, PO, daily
in AM
• May increase to 600 mg,
PO, BID on day 4 of
treatment
• Not interchangeable with
other formulations
• Do not crush, cut, or chew
• Dose adjustment required in kidney
disease
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11. Prescribing Information - Horizant (Gabapentin enacarbil). accessdata.fda.gov. Published December 2012. Accessed June 23, 2021.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022399s006,s007lbl.pdf

11. Treatment -
Gabapentinoids/GABA Analogues (cont.)
BRAND GENERIC DOSE MONITORING
Lyrica® Pregabalin​
• Start at 150 mg PO BID or
TID.
• Max daily dose = 600 mg
• ​Worsening depression
• Suicidal ideas/behavior
• Facial swelling
• Sedation, especially on initiation
• Increased risk of seizures on abrupt
withdrawal
• Requires dose adjustment in kidney
disease
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6. Highlights of Prescribing Information - Lyrica (Pregabalin). Pfizer.com. Published June 2020. Accessed June 23, 2021. http://labeling.pfizer.com/showlabeling.aspx?id=561

12. Treatment - Topicals
BRAND GENERIC DOSE MONITORING
Lidoderm®
(patch)
Xylocaine®
(ointment)
Lidocaine, 5%
• 700 mg lidocaine/patch
• 2100 mg lidocaine/3 patches
maximum at once
• Patches *CAN* be cut
• Skin irritation (change site)
• Sleepiness
• For patch, apply to site of pain 12 hours
on, 12 hours off
• For patch, do not exceed 3 patches at
once
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2. Prescribing Information - LIDODERM® (Lidocaine Patch 5%). Endo.com. Published November 2018. Accessed June 17, 2021.
https://www.endo.com/File%20Library/Products/Prescribing%20Information/LIDODERM_prescribing_information.html
12. Prescribing Information - Xylocaine® Ointment, 5% (Lidocaine Ointment, USP) 50 Mg/G Topical Anesthetic. AstraZeneca Canada Inc.; 2006:1-18. Accessed June 23, 2021.
https://pdf.hres.ca/dpd_pm/00003402.PDF

13. Treatment - Topicals (cont.)
BRAND GENERIC DOSE MONITORING
Qutenza®
(patch)
Capsaicin, 8%
(cream or patch)
• Apply for 60 minutes under
supervision of a physician
• Up to 4 patches may be applied
simultaneously
• May be repeated no earlier than
every 3 months
• Patches *CAN* be cut
• Assess skin integrity. Do not apply
to broken skin
• Use a face mask in a well-
ventilated area when applying
• Remove from package gently and
slowly
• Wear nitrile gloves when applying
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10. Prescribing Information - Qutenza® (Capsaicin) Topical System. AveritasPharma; 2020:1-17. Accessed June 23, 2021. https://www.qutenza.com/pdfs/Qutenza_Prescribing_Information.pdf

14. Topical Ketamine?
 The International Journal of Pharmaceutical Compounding, 2016
 Open-label trial
 Treatment is known by all
 Methods:
 Up to 4g of topical ketamine (10%) applied TID for 2 weeks
 Subjects recorded pain in on a 10-point scale at the time of application and
one hour later in a journal
 0 = no pain, 5 = moderate pain, 10 = worst possible pain
 Subjects also recorded adverse events and degree of satisfaction in the
journal
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13. Rabi J, Minori J, Abad H, Lee R, Gittler M. Topical Ketamine 10% for Neuropathic Pain in Spinal Cord Injury Patients: An Open-Label Trial. International Journal of Pharmaceutical
Compounding. 2016;20(6):517-520. https://ijpc.com/Abstracts/Abstract.cfm?ABS=4254

15. Topical Ketamine? (cont.)
 The good:
 Every subject experienced a reduction in pain
 Reductions ranged from 14-63%
 Reductions lasted until the next application in 80% of subjects
 No adverse effects
 No missed doses during the study
 The bad:
 N = 5 (very small sample size)
 Short duration
 Lacked a placebo group
 Every patient was taking at least 1 concurrent pain medication
 Blood levels to assess absorption were not performed
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16. Questions?
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17. References
1. Bates D, Schultheis BC, Hanes MC, et al. A Comprehensive Algorithm for Management of Neuropathic Pain. Pain Medicine.
2019;20(Supplement 1):S2-S12. doi:10.1093/pm/pnz075
2. Prescribing Information - LIDODERM® (Lidocaine Patch 5%). Endo.com. Published November 2018. Accessed June 17, 2021.
https://www.endo.com/File%20Library/Products/Prescribing%20Information/LIDODERM_prescribing_information.html
3. Prescribing Information - EFFEXOR XR® (Venlafaxine Extended-Release) Capsules. Wyeth Pharmaceuticals (a subsidiary of
Pfizer Inc.); 2017:1-40. Accessed June 17, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020699s107lbl.pdf
4. Prescribing Information - Cymbalta® (Duloxetine Hydrochloride) Capsules. Eli Lilly and Company; 2010:1-33. Accessed June
17, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf
5. Prescribing Information - Gralise® (Gabapentin) Tablets. Gralise.com. Published April 2020. Accessed June 17, 2021.
https://www.gralise.com/pdfs/gralise-prescribing-information.pdf
6. Highlights of Prescribing Information - Lyrica (Pregabalin). Pfizer.com. Published June 2020. Accessed June 23, 2021.
http://labeling.pfizer.com/showlabeling.aspx?id=561
17

18. References (cont.)
7. Product Monograph - Aventyl (Nortriptyline Hydrochloride). AA Pharma; 2014:1-17. Accessed June 23, 2021.
https://www.aapharma.ca/downloads/en/PIL/Aventyl_PM.pdf
8. Prescribing Information - Amitriptyline. Published September 15, 2017. Accessed June 23, 2021.
https://pdf.hres.ca/dpd_pm/00041275.PDF
9. Prescribing Information - Neurontin (Gabapentin). Pfizer; 2017:1-37. Accessed June 23, 2021.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020235s064_020882s047_021129s046lbl.pdf
10. Prescribing Information - Qutenza® (Capsaicin) Topical System. AveritasPharma; 2020:1-17. Accessed June 23,
2021. https://www.qutenza.com/pdfs/Qutenza_Prescribing_Information.pdf
11. Prescribing Information - Horizant (Gabapentin enacarbil). accessdata.fda.gov. Published December 2012. Accessed June 23,
2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022399s006,s007lbl.pdf
12. Prescribing Information - Xylocaine® Ointment, 5% (Lidocaine Ointment, USP) 50 Mg/G Topical Anesthetic. AstraZeneca
Canada Inc.; 2006:1-18. Accessed June 23, 2021. https://pdf.hres.ca/dpd_pm/00003402.PDF
18

19. References (cont.)
13. Rabi J, Minori J, Abad H, Lee R, Gittler M. Topical Ketamine 10% for Neuropathic Pain in Spinal Cord Injury Patients: An
Open-Label Trial. International Journal of Pharmaceutical Compounding. 2016;20(6):517-
520. https://ijpc.com/Abstracts/Abstract.cfm?ABS=4254
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20. Paul Pasco, PharmD
Candidate
ppasco@uthsc.edu
UTHSC College of Pharmacy
Thursday, June 24, 2021
20