DrJed Talks: Nerve pain and Treatment. Gabapentin, Lyrica, Cymbalta. Full discussion.

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Hello, Dr.

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Jed here. Today we’re talking about nerve pain

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and the medical treatment of nerve pain.

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So in doctor speak, nerve pain is sometimes referred to

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as neuropathic pain, neurogenic pain,

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perhaps radicular pain.

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Radi means root as in nerve root.

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Cervical radicular pain

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or cervical radiculopathy would be a

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pinched nerve in the neck.

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Lumbar radiculopathy would be a pinched nerve.

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In the low back, uh, there is sometimes sciatica

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that’s essentially the same thing,

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a pinched nerve typically in the low back, causing pain down

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to the lower extremity.

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Now, nerve pain has many, many, many descriptors

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and can be experienced many, many different ways.

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It is oftentimes felt as painful. Paresthesias.

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Paresthesia simply means that numbness, tingling pins

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and needles, uh, to my Spanish speaking patients, uh, dorm,

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that as if it’s gone to sleep,

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waking back up the pins and needles.

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So, nerve pain can also oftentimes be experienced

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as a dull deep, a dull deep aching,

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sometimes difficult to localize.

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That is in the category of

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what you might call proto pathic pain.

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Now, there’s another category

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of nerve pain called epicritic pain.

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That is the sharp lancinating shooting pain,

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the electrical shock pain.

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And, uh, both of those styles

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of pain are actually carried on different nerve fibers,

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but we’re not specifically taking a deep dive into the

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physiology of nerve pain today.

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So enough said on that.

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Uh, in general we’ll keep it very broad

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and just refer to it as nerve pain.

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The neurogenic pain probably referred to as the, uh,

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radiculopathies as well.

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So the causes of nerve pain, there are many, many,

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many causes of nerve pain to begin with.

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You could divide them into overall two separate domains.

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Okay? One domain would be that of nerve entrapments,

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nerve impingement.

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That is the direct pinching of a nerve,

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the direct damage of a nerve.

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Uh, the pinching of a nerve might happen in the neck.

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Once again, that would be cervical radiculopathy,

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a pinched nerve in the neck, lumbar radiculopathy.

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O oftentimes you may use the, uh, term radicular pain

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or radiculitis if it doesn’t quite meet the threshold

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of true radiculopathy.

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Once again, uh, the threshold

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of radiculopathies would be focal sensory and

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or motor deficits backed up with some, uh, special testing

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that your Dr. May do.

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So other causes of nerve pains in the domain

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of the nerve entrapments would be, um,

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peripheral nerve enchantments.

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Say for example, here in my elbow, uh,

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the ulnar nerve comes right around there,

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innervates those two fingers right there. And,

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Um, sometimes the nar nerve is the nerves are

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very much like a wire.

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Uh, sometimes a person’s wire,

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the NAR nerve has simply gotten worn out there.

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Um, the myelin that is the insulation

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around the nerve has gotten worn thin

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and is now causing pain.

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That would be called ulnar neuropathy about the elbow.

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Uh, another very common entrapment

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that probably everybody’s heard of is called carpal tunnel.

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And that would be the median nerve

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entrapped right here at the wrist.

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And that is oftentimes felt in these

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three fingers right here.

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We call that digit one, two, three. Uh, let’s see here.

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Now to make things extra tricky,

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if you have what’s called a C six radiculopathy,

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that would be, um, a pinched C six nerve root.

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You might get sensations right there in digits one,

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two versus the, uh,

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carpal tunnel is 1, 2, 3.

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And it’s oftentimes very difficult to peel those apart.

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Uh, once again, not every human body has read all the

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textbooks and everything doesn’t line up exactly as we are,

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let to believe when we’re going through medical school.

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But in general, that can be the six shooter.

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The, uh, C six, and that can be the, uh,

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carpal tunnel syndrome.

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That could be ulnar neuropathy.

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This could also be a C eight, maybe a T one radiculopathy.

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Uh, once again, down in the lower extremities, um,

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some peripheral nerve entrapments that may happen there.

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On the outside of the knee,

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you may get what’s called a peroneal entrapment about the

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fibular head that can give weakness.

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Perhaps it could lead to foot drop.

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You couldn’t lift your foot, uh, give you that pins

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and needles, um, the neuropathic pain down into the, uh,

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front of the leg, the top of the foot.

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You can also have another one further down on the,

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on the instep, so to speak, so to speak.

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And that would be, uh,

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tibial entrapment at the tarsal tunnel.

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Much more rare than carpal tunnel,

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but it is a potential entrapment.

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There are many and many other nerve entrapments.

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But uh, that will suffice it for now

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for like a general discussion

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of the common nerve entrapments.

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Now, other potential causes of the entrapment,

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the direct injury of nerve pain could just be direct injury.

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Well, what if you fell down

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and you nailed your funny bone, really hard on a piece

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of steel that can cause nerve pain.

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Uh, similarly, trauma accidents. You break your arm.

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That can cause, uh, direct nerve injury.

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Sometimes you can have a much delayed nerve injury.

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Say for example, if you break your humerus many,

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many years later, as the bone callous grows up, it can begin

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to impinge upon a nerve

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and that it can eventually cause what’s called tardy

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Palsy. Tardy

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means late so many, many causes

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of the nerve impingement,

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the nerve entrapments the direct nerve damage.

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So the other domain of nerve pain is the neuropathies.

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Neuropathy in general is simply a disease state

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that is adversely affecting the healthier nerves.

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And that translates to your nerves not conducting normally.

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Sometimes the messages make it up to your brain

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and interpret it all kinds of different ways.

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Sometimes becomes very painful,

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not necessarily always painful.

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Uh, sometimes people describe this

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as vice-like, uh, tight.

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Uh, I’ve had some patients that kept buying larger

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and larger shoes ’cause they thought their

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shoes were too tight.

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Uh, in fact, he just had a pretty bad peripheral neuropathy.

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Other symptoms of the peripheral neuropathy can eventually

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include impaired proprioception.

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That is an impaired ability to understand

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where your feet are in space and time.

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And that can be complicated, that can complicate it.

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If you’re walking through your house at night

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and maybe you don’t see a rolled up carpet or a cat

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or an edge or something,

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other times neuropathies can progress enough to

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where you get overt weakness.

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So the causes of a peripheral neuropathy are many,

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many and many.

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Okay. Uh, I oftentimes use a little bit

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of hyperbole in clinic

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and I say there are a thousand known causes

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of a peripheral neuropathy.

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Uh, now that’s probably not actually an exaggeration,

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but I could just sit right here

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and lift off list off several dozen.

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But let’s go over the top few most common.

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So in America and most of the industrialized nations,

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it would go something like this for 1, 2, 3, diabetes,

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alcohol, and thyroid disease.

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So notice that number one is diabetes.

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Many and many people think, well,

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peripheral neuropathy equals diabetes.

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If I don’t have diabetes,

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I don’t have a peripheral neuropathy.

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No, no, no. There’s those 999 other causes

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of a peripheral neuropathy.

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So once again, diabetes, alcohol, thyroid disease,

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kidney disease, renal disease that would lead

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to electrolyte imbalances, which makes it difficult

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for your nerves to continue to function well.

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There are various autoimmune diseases

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where you essentially attack your own nerves

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and can induce a neuropathy.

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Some infections are known to cause a peripheral neuropathy.

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HIV has a well-defined peripheral neuropathy

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associated with that.

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I don’t think dip theory is very common anymore.

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However, it was certainly associated

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with peripheral neuropathies.

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Uh, also Lyme disease can be associated

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with peripheral neuropathies.

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There are various vitamin deficiencies.

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Uh, the vitamin B12, uh, folate.

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Um, I’ve heard it said back in the day

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that oftentimes people that had a peripheral neuropathy,

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they would give them a shot of B vitamins.

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However, it turned out

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that too much B vitamins could also

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cause a peripheral neuropathy.

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So that practice was stopped.

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Um, if you are treating your peripheral neuropathy

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with B vitamins, I would make sure

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you have checked with your doctor.

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And if you have low levels of B vitamins, by all means treat

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with the B vitamins.

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If you do not have low levels of B vitamins,

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perhaps you are contributing to your peripheral neuropathy

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by supplementing too much B vitamins.

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Other potential causes

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of a peripheral neuropathy are various medications.

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Many medications are known to cause a peripheral neuropathy.

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Probably the most common offenders are

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chemotherapeutic agents.

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Chemotherapy, once again, is essentially selective poison

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that you’re using to try to kill cancer cells

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or other specific cells in the body.

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And sometimes they cause collateral damage.

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Once again, the nerves do a very complex job

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and if they get damaged,

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then you have a peripheral neuropathy.

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So that leads us now to the toxic exposures.

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There are many and many toxic exposures

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that can cause a peripheral neuropathy.

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Some of these may be, uh, cleaning agents, uh,

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particularly cleaning solvents.

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They’re used to dissolve grease.

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Um, acrylamide is a known, uh, toxic agent

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that can cause a peripheral neuropathy.

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Um, other things such as adhesives, I could go

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and read out a whole list of 50 things that are known

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to cause a peripheral neuropathy.

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The thing is, if you have any doubt at all,

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make sure you use your protective equipment if you are

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working around any substances

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that you’re suspicious with at all.

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So to review, in general, causes

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of nerve pain may be from the neural entrapments,

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the pinched nerve in the, the neck, the low back,

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or other places in the body versus the neuropathies

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peripheral neuropathy, diabetic peripheral neuropathy.

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So what do we do about this?

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Well, the treatment of nerve pain can be very difficult.

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Nerve pain can be very resistant to standard medications

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to treat pain such as ibuprofen.

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Tylenol doesn’t really seem to do much.

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Even the narcotic pain medicines don’t treat

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nerve pain very well.

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So what are the standard treatments for nerve pain?

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The primary medical treatments for neuropathic pain

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that is nerve pain are the big three.

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So, uh, the most commonly used is gabapentin followed

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not in two distant second by Lyrica, also called pregabalin,

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and then Cymbalta.

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Those will be the big three medications that can be used

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to treat neuropathic pain to treat nerve pain.

252
00:11:37.905 –> 00:11:41.485
Now a quick survey of the internet might indicate,

253
00:11:41.545 –> 00:11:44.365
you might see, oh, gabapentin, uh, one,

254
00:11:44.365 –> 00:11:45.565
it has all these side effects.

255
00:11:46.015 –> 00:11:48.405
Gabapentin wasn’t even invented for nerve pain.

256
00:11:48.545 –> 00:11:51.365
It was invented to treat seizures like, well,

257
00:11:51.445 –> 00:11:52.805
I don’t have seizures, doc, why are

258
00:11:52.805 –> 00:11:54.085
You giving me this medication?

259
00:11:54.675 –> 00:11:57.005
Well, it turns out that for many

260
00:11:57.025 –> 00:11:59.805
and many people, gabapentin worked pretty well

261
00:11:59.805 –> 00:12:01.085
to decrease the nerve pain.

262
00:12:01.465 –> 00:12:05.245
Um, I have seen one particular study that has suggests

263
00:12:05.245 –> 00:12:06.845
that maybe it doesn’t work that great,

264
00:12:07.145 –> 00:12:10.525
but anecdotally of the thousands of patients I’ve given it

265
00:12:10.525 –> 00:12:13.485
to, sure there are some patients it doesn’t work.

266
00:12:13.665 –> 00:12:16.205
But there are many and many patients it does work.

267
00:12:16.625 –> 00:12:18.485
So it’s worth a try

268
00:12:18.505 –> 00:12:20.005
for the most part is what I’m saying here.

269
00:12:20.945 –> 00:12:25.045
Uh, gabapentin. Now let’s speak about gabapentin dosing.

270
00:12:25.255 –> 00:12:28.205
There are many and many and many and many

271
00:12:28.345 –> 00:12:31.085
and many steps to dosing gabapentin.

272
00:12:31.365 –> 00:12:34.485
A daily max dose for gabapentin would be 3,600 milligrams.

273
00:12:35.525 –> 00:12:40.255
I typically abide by the mantra of start low and go slow.

274
00:12:40.875 –> 00:12:43.095
So I oftentimes implement gabapentin

275
00:12:43.165 –> 00:12:46.335
with the 100 milligrams, uh, the bottle.

276
00:12:49.035 –> 00:12:53.275
I typically begin dosing gabapentin with the 100 milligrams,

277
00:12:53.555 –> 00:12:54.715
I typically right

278
00:12:54.815 –> 00:12:58.315
for the bottle may say take two, three times a day.

279
00:12:58.635 –> 00:13:00.675
I oftentimes advise patients to

280
00:13:01.605 –> 00:13:04.115
begin maybe taking just the bedtime dose at first

281
00:13:04.115 –> 00:13:05.755
because the most common side effect

282
00:13:05.755 –> 00:13:07.875
of gabapentin is sleepiness.

283
00:13:07.875 –> 00:13:10.875
It can make you very sleepy. Uh, as the doses get higher.

284
00:13:10.985 –> 00:13:14.595
Sometimes people note cognitive side effects, meaning, uh,

285
00:13:14.865 –> 00:13:17.875
they say it word processing gets more difficult.

286
00:13:18.455 –> 00:13:20.875
Um, they just sometimes don’t feel

287
00:13:20.935 –> 00:13:22.435
as sharp as they would like to.

288
00:13:22.855 –> 00:13:26.275
So let’s begin low and then go slow.

289
00:13:26.415 –> 00:13:29.155
So those one hundreds maybe eventually dosing up

290
00:13:29.155 –> 00:13:32.275
to 200 milligrams three times a day.

291
00:13:32.855 –> 00:13:36.975
So, uh, I want to convey is some another, I want

292
00:13:36.975 –> 00:13:38.335
to convey another point here,

293
00:13:38.355 –> 00:13:42.375
and that is there’s no magic to dosing gabapentin.

294
00:13:42.375 –> 00:13:46.415
Okay? So, uh, imagine that your hand is on the knob

295
00:13:46.955 –> 00:13:48.455
of a stereo, okay?

296
00:13:48.675 –> 00:13:49.855
The volume of the stereo.

297
00:13:50.435 –> 00:13:52.935
If you want more volume, you just turn the volume up.

298
00:13:52.935 –> 00:13:54.135
So you hear the music louder.

299
00:13:54.555 –> 00:13:56.455
Uh, if that’s too much, you turn it down.

300
00:13:56.875 –> 00:13:58.455
So within the dosing parameters

301
00:13:58.635 –> 00:14:00.775
of those 100 milligram tablets

302
00:14:00.775 –> 00:14:04.535
or capsules, uh, if it says take two, three times a day,

303
00:14:04.915 –> 00:14:08.055
if you find it sufficient that you take 200 milligrams

304
00:14:08.055 –> 00:14:11.375
of bedtime and maybe 100 milligrams in the morning time

305
00:14:11.555 –> 00:14:13.415
and that’s fine, then that’s fine.

306
00:14:13.715 –> 00:14:16.135
You don’t have to take all those doses

307
00:14:16.135 –> 00:14:18.055
of gabapentin’s completely acceptable.

308
00:14:18.635 –> 00:14:20.495
So let’s say you’ve dosed up,

309
00:14:20.595 –> 00:14:23.415
you’ve titrated up your gabapentin dosing

310
00:14:23.635 –> 00:14:27.015
to include 200 milligrams three times a day.

311
00:14:27.995 –> 00:14:29.855
You might come back and talk it over to your doctor.

312
00:14:30.155 –> 00:14:31.575
If you’re my patient, you’re coming back

313
00:14:31.575 –> 00:14:32.655
and you’re talking over with me,

314
00:14:32.995 –> 00:14:35.415
at which case we might increase the dose

315
00:14:35.635 –> 00:14:37.495
to the 300 milligram capsules.

316
00:14:37.835 –> 00:14:41.335
We might just say 300 milligram capsules three times a day.

317
00:14:41.725 –> 00:14:45.335
Alternately we might just say 300 milligram capsules.

318
00:14:45.515 –> 00:14:48.695
And the bottle will say, take two, three times a day.

319
00:14:49.035 –> 00:14:50.695
And now this follows the same mantra,

320
00:14:51.155 –> 00:14:53.085
Meaning you don’t have to jump right

321
00:14:53.085 –> 00:14:55.365
to taking 600, 600, 600,

322
00:14:55.735 –> 00:14:59.005
maybe you take 300 in the morning, 300 in the middle

323
00:14:59.005 –> 00:15:01.725
of a day, and then you take 600 at bedtime.

324
00:15:01.935 –> 00:15:03.285
Completely acceptable.

325
00:15:03.745 –> 00:15:07.765
Uh, I have some patients that maybe take something like that

326
00:15:08.265 –> 00:15:10.645
and then 900 milligrams at bedtime

327
00:15:10.955 –> 00:15:12.245
also completely acceptable.

328
00:15:13.965 –> 00:15:15.945
So let’s say for example, you come back to your doctor

329
00:15:15.945 –> 00:15:19.505
after a month or so of trying that gabapentin dosing up

330
00:15:19.505 –> 00:15:21.265
to 600 milligrams three times a day.

331
00:15:21.415 –> 00:15:24.145
That would be a total dose of 1800 milligrams per day,

332
00:15:24.195 –> 00:15:25.785
which is a reasonable dose.

333
00:15:26.485 –> 00:15:29.465
By the time you’re taking 1800 milligrams a day,

334
00:15:29.645 –> 00:15:31.385
you might truly be decreasing

335
00:15:31.415 –> 00:15:33.585
that neuropathic pain that you’ve been experiencing.

336
00:15:34.075 –> 00:15:37.025
Let’s say for example, maybe it’s making a difference,

337
00:15:37.045 –> 00:15:38.265
but maybe not quite enough.

338
00:15:38.685 –> 00:15:40.785
You might titrate it up a little bit more.

339
00:15:40.965 –> 00:15:43.305
And that would be maybe the 900 milligrams

340
00:15:43.595 –> 00:15:44.625
three times a day.

341
00:15:45.225 –> 00:15:48.265
I rarely go above that dose, uh, occasionally

342
00:15:48.265 –> 00:15:50.545
to 900 milligrams four times a day,

343
00:15:50.805 –> 00:15:53.225
or 1200 milligrams three times a day.

344
00:15:53.405 –> 00:15:55.065
And that would take you to the max dose,

345
00:15:55.115 –> 00:15:58.785
which would be 3,600 milligrams for the daily max dose.

346
00:15:58.805 –> 00:16:01.465
For a gabapentin, let’s say for example,

347
00:16:01.465 –> 00:16:05.065
you get up there someplace 2,400 milligrams a day or greater

348
00:16:05.685 –> 00:16:07.705
and it’s just not working for you

349
00:16:07.925 –> 00:16:11.905
or you are having side effects, you say, Hey doc,

350
00:16:12.025 –> 00:16:13.825
I just have trouble waking up in the morning,

351
00:16:13.825 –> 00:16:14.985
staying focused at work.

352
00:16:15.225 –> 00:16:18.065
I can’t do some of the cognitive tasks that I need to.

353
00:16:18.415 –> 00:16:22.545
Then your physician then has the information to put in the,

354
00:16:22.645 –> 00:16:26.705
in the chart note to get you Lyrica, uh, lyrica

355
00:16:27.275 –> 00:16:28.665
slash pregabalin.

356
00:16:29.225 –> 00:16:31.985
I term it oftentimes as gabapentin’s new

357
00:16:32.045 –> 00:16:35.145
and improved cousin is supposed to be cleaner,

358
00:16:35.455 –> 00:16:37.865
have fewer side effects, maybe work better,

359
00:16:38.165 –> 00:16:39.585
and that’s not always the case.

360
00:16:40.105 –> 00:16:43.985
I have had some patients that had titrated up, Lyrica,

361
00:16:44.285 –> 00:16:46.825
wasn’t working for them, went back to gabapentin,

362
00:16:46.825 –> 00:16:48.905
and gabapentin seemed to be the better medicine.

363
00:16:49.015 –> 00:16:51.545
However, in general, it seems

364
00:16:51.855 –> 00:16:53.545
that Lyrica is a little cleaner.

365
00:16:53.795 –> 00:16:55.945
Fewer side effects works a little bit better.

366
00:16:56.565 –> 00:16:59.465
So the dosing on Lyrica is very different.

367
00:16:59.805 –> 00:17:04.145
Uh, the max daily dose for Lyrica is 600 milligrams per day.

368
00:17:04.645 –> 00:17:08.905
Uh, oftentimes if a person has not had Lyrica yet,

369
00:17:09.175 –> 00:17:12.265
I’ll begin maybe the 25 milligrams three times a day.

370
00:17:12.645 –> 00:17:14.985
Uh, maybe at the 50 milligrams three times a day.

371
00:17:15.725 –> 00:17:20.465
So once again, you titrate this up to effect.

372
00:17:20.575 –> 00:17:22.945
Okay? So you might take that, uh,

373
00:17:23.075 –> 00:17:26.065
50 milligrams once in the morning and once in the evening,

374
00:17:26.605 –> 00:17:28.865
and maybe for those first few days, if you take,

375
00:17:29.855 –> 00:17:31.275
if you took it all three times,

376
00:17:31.645 –> 00:17:33.315
maybe you’re very sleepy in the afternoon.

377
00:17:33.495 –> 00:17:34.715
So perhaps it works best for you

378
00:17:34.715 –> 00:17:36.755
to take 50 milligrams in the morning

379
00:17:37.175 –> 00:17:39.075
and then 100 milligrams at bedtime.

380
00:17:39.135 –> 00:17:40.475
So you can get a good night’s sleep,

381
00:17:41.475 –> 00:17:44.035
whatever the case may be, 50 milligrams three times a

382
00:17:44.035 –> 00:17:45.235
day, that’s reasonable.

383
00:17:45.655 –> 00:17:47.715
Say for example, you’re taking that dose,

384
00:17:48.145 –> 00:17:50.205
it’s helping a little bit, but not enough.

385
00:17:50.505 –> 00:17:51.565
You come back to your doctor,

386
00:17:51.785 –> 00:17:53.965
you have the talk, you can increase.

387
00:17:54.295 –> 00:17:56.965
Maybe you just go to 75 milligrams three times a day.

388
00:17:57.175 –> 00:17:59.605
Maybe you go to 100 milligrams three times a day.

389
00:18:00.115 –> 00:18:01.565
There’s no particular magic.

390
00:18:01.675 –> 00:18:03.525
There’s a discussion with your physician

391
00:18:03.525 –> 00:18:06.045
and then you advance as appropriate, uh,

392
00:18:06.045 –> 00:18:07.605
as a team working together.

393
00:18:07.795 –> 00:18:11.765
Okay? Eventually you might get get up as high as

394
00:18:12.465 –> 00:18:14.085
100 milligrams three times a day,

395
00:18:14.325 –> 00:18:16.645
150 milligrams three times a day.

396
00:18:16.675 –> 00:18:17.885
That used to be the max dose

397
00:18:17.885 –> 00:18:21.365
of Lyrica is 450 milligrams, uh, per day.

398
00:18:21.815 –> 00:18:26.605
These days, the max daily dose for Lyrica is 600 milligrams.

399
00:18:27.025 –> 00:18:30.445
So you might take 200 milligrams three times a day.

400
00:18:30.805 –> 00:18:31.925
I do have a couple patients

401
00:18:31.925 –> 00:18:36.325
that take 300 milligrams twice a day, sticking within that,

402
00:18:36.465 –> 00:18:40.565
uh, cap of 600 milligrams of Lyrica for the day.

403
00:18:41.105 –> 00:18:45.485
Now the last medicine, Cymbalta, there’s some literature

404
00:18:45.485 –> 00:18:48.525
that suggests that Cymbalta may be the single best

405
00:18:48.615 –> 00:18:51.205
medication to treat neuropathic pain.

406
00:18:51.745 –> 00:18:55.045
So why don’t I begin with Cymbalta? Many reasons.

407
00:18:55.635 –> 00:18:57.725
Some of the main reasons might be just

408
00:18:57.915 –> 00:18:59.245
insurance stipulations.

409
00:18:59.705 –> 00:19:03.245
Myself, I’m a physiatrist. I’m not a psychiatrist.

410
00:19:03.835 –> 00:19:06.845
Psychiatrists oftentimes use Cymbalta

411
00:19:06.905 –> 00:19:09.125
to perhaps treat depression and

412
00:19:09.145 –> 00:19:12.205
or other various mood disorders.

413
00:19:12.395 –> 00:19:15.925
However, as that is not in my wheelhouse, I’m using Cymbalta

414
00:19:15.925 –> 00:19:17.445
to treat neuropathic pain.

415
00:19:17.875 –> 00:19:21.325
Typically, the guidelines that are placed there,

416
00:19:21.555 –> 00:19:23.725
thereby insurance, stipulate

417
00:19:23.725 –> 00:19:27.085
that I must try other medications first, try

418
00:19:27.085 –> 00:19:28.285
and fail other medications

419
00:19:28.345 –> 00:19:30.525
before they will approve Cymbalta.

420
00:19:31.145 –> 00:19:33.845
So that will oftentimes include dosing

421
00:19:33.845 –> 00:19:36.245
and trialing the gabapentin,

422
00:19:36.275 –> 00:19:38.205
sometimes going up trying the Lyrica.

423
00:19:38.465 –> 00:19:40.765
And if a person is still having neuropathic pain,

424
00:19:41.035 –> 00:19:43.405
then progressing to the Cymbalta.

425
00:19:44.165 –> 00:19:45.805
Cymbalta dosing is a little bit different.

426
00:19:46.145 –> 00:19:49.445
It is oftentimes dosed either once daily or twice daily.

427
00:19:49.965 –> 00:19:52.525
I typically do it twice daily myself.

428
00:19:52.725 –> 00:19:55.125
’cause once again, I’m trying to treat neuropathic pain

429
00:19:55.125 –> 00:19:56.245
and not a mood disorder.

430
00:19:56.635 –> 00:19:57.845
I’ll begin very low.

431
00:19:58.305 –> 00:20:02.365
Say for example, Cymbalta 20 milligrams twice a day,

432
00:20:03.015 –> 00:20:04.165
maybe do that for a month.

433
00:20:04.165 –> 00:20:06.645
You come back, we might go to 30 milligrams twice a day.

434
00:20:06.985 –> 00:20:09.045
You might go to 40 milligrams twice a day,

435
00:20:09.065 –> 00:20:10.245
up to 80 milligrams.

436
00:20:11.165 –> 00:20:13.165
Occasionally some patients will want to switch over

437
00:20:13.165 –> 00:20:14.485
to 80 milligrams once a day.

438
00:20:14.785 –> 00:20:17.285
And that case, that is acceptable in that case.

439
00:20:17.405 –> 00:20:19.405
Nothing wrong with that. And, um,

440
00:20:19.795 –> 00:20:23.765
once you’re at 80 milligrams, there is a literature

441
00:20:23.765 –> 00:20:26.685
that suggests that increasing the dose beyond

442
00:20:26.685 –> 00:20:29.525
that won’t make much of a difference in decreasing the pain.

443
00:20:29.555 –> 00:20:32.005
However, I have a couple patients that say

444
00:20:32.005 –> 00:20:35.285
otherwise that say that once they got to 120 milligrams,

445
00:20:35.285 –> 00:20:36.605
that made a big difference for them.

446
00:20:36.755 –> 00:20:39.205
However, in general, once you’re up

447
00:20:39.205 –> 00:20:41.405
to 80 milligrams a day on Cymbalta,

448
00:20:41.985 –> 00:20:44.245
you’re probably not gonna get much more benefit in

449
00:20:44.245 –> 00:20:45.805
decreasing that neuropathic pain.

450
00:20:47.425 –> 00:20:50.685
So that’s a quick review of the medication dosing

451
00:20:50.905 –> 00:20:54.085
and the medication use to treat neuropathic pain.

452
00:20:54.345 –> 00:20:56.525
Now there are many other specific treatments

453
00:20:57.145 –> 00:20:58.605
for neuropathic pain.

454
00:20:58.605 –> 00:21:00.605
However, those are very specific

455
00:21:00.865 –> 00:21:03.365
to very specific pathologies.

456
00:21:03.665 –> 00:21:06.325
In particular, specific to cases

457
00:21:06.545 –> 00:21:08.885
of pinched nerves in the neck

458
00:21:08.905 –> 00:21:11.285
or the back where you may be a candidate for injections.

459
00:21:11.955 –> 00:21:15.285
Similarly, there in both in the uh, low back,

460
00:21:15.285 –> 00:21:17.725
particularly people may be a candidate

461
00:21:17.745 –> 00:21:19.725
for what’s called a spinal cord stimulator.

462
00:21:19.725 –> 00:21:22.405
There’s also there evolving technology

463
00:21:22.585 –> 00:21:24.965
of peripheral nerve stimulators.

464
00:21:25.345 –> 00:21:27.605
All these things continue to advance

465
00:21:27.665 –> 00:21:31.125
and continue to offer more options for the treatment

466
00:21:31.225 –> 00:21:32.645
of neuropathic pain,

467
00:21:32.645 –> 00:21:35.165
which once again is very difficult to treat.

468
00:21:36.025 –> 00:21:40.045
If you have neuropathic pain, you begin with gabapentin,

469
00:21:40.225 –> 00:21:41.805
Lyrica, Cymbalta.

470
00:21:41.865 –> 00:21:45.165
If you continue to have neuropathic pain, you speak

471
00:21:45.165 –> 00:21:47.685
with your physician and see if there are other options

472
00:21:47.685 –> 00:21:49.525
that you can treat your neuropathic pain

473
00:21:49.625 –> 00:21:52.205
to help you live your life, less pain,

474
00:21:52.635 –> 00:21:54.845
improve your function, improve your mood,

475
00:21:54.955 –> 00:21:56.525
just improve your quality of life.

476
00:21:57.025 –> 00:21:58.605
So hopefully you find this helpful.

477
00:21:58.875 –> 00:22:01.165
Once again, continue to take care of yourselves and be.