Elderly with Resistant Post Herpetic Neuralgia – What do You Do?

Not a new study but the benefits  mandated that I include it. Study presented were 2 cases in their 80’s with severe Post Herpetic Neuralgia – one on face, other T8-10 that tried everything including spinal stimulator without effect. Pain level was 10/10. Relief was gradually obtained by increasing doses of Nabilone, starting with 0.5 mg hs and working up over 1 year to 4 mg hs – got pain down to 4/10 without opioids. Having gone generic, cost is not prohibitive .

Ong‐Lam, M., and S. Basic.
699 TREATMENT OF REFRACTORY POST HERPETIC NEURALGIA WITH NABILONE.
European Journal of Pain 13.S1 (2009).
https://onlinelibrary.wiley.com/doi/pdf/10.1016/S1090-3801%2809%2960702-3
no abstract

  • 2 cases – 84 and 85 – pain 10/10

tried:

  • Tricyclic antidepressants (like amitriptyline)
  • opioids
  • lyrica 600 mg/day
  • gabapentin 1800 mg/day
  • lidocaine infusion
  • intercostal nerve blocks
  • TENS
  • spinal cord stimulation

 

  • Started on cesamet (nabilone) 0.5 mg hs and titrated to 4.0 mg hs (at bedtime) over 1 year
  • pain dropped to 4/10 and subjects were able to stop opioids

Comment – these are “golden cases” – cases that respond and not all are going to do so well. However  this becomes a viable option. Is is so refreshing to find something that works in the elderly.

addendum

Came across case of a 36 year old with resistant trigeminal neuralgia and atypical headaches treated with now extinct form of cannibis called dronabinol

pain medicine 18(3) march 2017 abstract 137
Refractory Trigeminal Neuralgia Treated Successfully with Dronabinol
Emily Davies

only an abstract so include part of it:

“Her pain intensity ranged from 6/10-10/10 on a numerical rating scale (NRS). Patient was given dronabinol for neuropathic pain with the goal of weaning off her polypharmacy medications. Dronabinol was initiated at 5mg twice daily for 1 week, then three times a day. Three weeks after initial pain evaluation, patient had completely self-weaned off her opioids, topiramate, butalbital product, zolpidem, and prochlorperazine, and reported zero migraines since dronabinol initiation. Three months after dronabinol initiation, patient’s pain intensity decreased 2/10 on a NRS, an objective decrease of 80% on only carbamazepine and dronabinol.

Discussion: This case demonstrates the successful use of dronabinol in decreasing TN pain and atypical HA pain, while directly impacting scheduled polypharmacy intake risk. Dronabinol should be considered as an adjunct or monotherapy for TN pain.

Comment – looks like chronic use gradually stabilized situation. I imagine other cannabinoids could have achieved similar results. cheap air max 95 cheap air max 95

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