Microsoft word - algorithm of np-updated 05-04.doc
Algorithm for Chronic Pain (by Mode of Action)
Proposed Mode of Action Therapeutic Category Medication Alpha II-Agonist Hypotensive Alpha II-Agonist Hypotensive AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anesthetic AMPA-Na Channel Blocker Anesthetic Anti-inflammatory Corticosteroid Anti-inflammatory Anti-inflammatory Anti-inflammatory Anti-inflammatory Calcium Channel Blocker Hypotensive Gaba Agonist Muscle Relaxant Gaba Agonist Benzodiazepine Increase Blood Flow Hemorheologic Mu Agonist Antidiarrheal Mu Agonist Mu Agonist NMDA-Ca Channel Blocker Antitussive NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Muscle Relaxant Substance P Analgesic Supplements Antiarthritic Supplements Antiarthritic Supplements Antoxidant Supplements Analgesic Supplements Analgesic Supplements Muscle Relaxant Supplements Muscle Relaxant Supplements Anti-inflammatory Supplements Analgesic Supplements Analgesic Synergy Tricyclic Antidepressant Antidepressant Tricyclic Antidepressant Antidepressant Tricyclic Antidepressant Antidepressant Notes: Ketamine 5%, Gabapentin 10%, Clonidine 0.2%, Baclofen 2% is standard starting regimen. (Formula # 7919) References: 1.Jones M. Chronic Neuropathic Pain: Pharmacological Interventions in the New Millenium - A Theory of Efficacy. International Journal of Pharmaceutical Compounding . Jan/Feb 2000; 4(1): 6-15. 2. Jones M. Clinical Nuggets and Pearls: Chronic Neuropathic Pain and Opioid Tolerance. International Journal of Pharmaceutical Compounding. Jan/Feb 2002; 6(1): 4-6.
Algorithm for Chronic Pain (by Medication)
Proposed Mode of Action Therapeutic Category Medication Tricyclic Antidepressant Antidepressant Gaba Agonist Muscle Relaxant Substance P Analgesic AMPA-Na Channel Blocker Anticonvulsant Gaba Agonist Benzodiazepine Alpha II-Agonist Hypotensive Tricyclic Antidepressant Antidepressant Anti-inflammatory Corticosteroid NMDA-Ca Channel Blocker Antitussive Anti-inflammatory AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant Supplements Antiarthritic Supplements Antiarthritic Anti-inflammatory Tricyclic Antidepressant Antidepressant NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic Anti-inflammatory AMPA-Na Channel Blocker Anesthetic Supplements Antoxidant Mu Agonist Antidiarrheal Supplements Analgesic Supplements Analgesic AMPA-Na Channel Blocker Anesthetic NMDA-Ca Channel Blocker Muscle Relaxant Supplements Muscle Relaxant Supplements Muscle Relaxant Mu Agonist Calcium Channel Blocker Hypotensive Supplements Anti-inflammatory Mu Agonist Increase Blood Flow Hemorheologic Alpha II-Agonist Hypotensive Anti-inflammatory Supplements Analgesic Supplements Analgesic Synergy Notes: Ketamine 5%, Gabapentin 10%, Clonidine 0.2%, Baclofen 2% is standard starting regimen. (Formula # 7919) References: 1. Jones M. Chronic Neuropathic Pain: Pharmacological Interventions in the New Millenium - A Theory of Efficacy. International Journal of Pharmaceutical Compounding . Jan/Feb 2000; 4(1): 6-15. 2. Jones M. Clinical Nuggets and Pearls: Chronic Neuropathic Pain and Opioid Tolerance. International Journal of Pharmaceutical Compounding. Jan/Feb 2002; 6(1): 4-6.
Algorithm for Chronic Pain (by Therapeutic Category)
Proposed Mode of Action Therapeutic Category Medication Substance P Analgesic Supplements Analgesic Supplements Analgesic Supplements Analgesic Supplements Analgesic Synergy NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic NMDA-Ca Channel Blocker Anesthetic AMPA-Na Channel Blocker Anesthetic AMPA-Na Channel Blocker Anesthetic Supplements Antiarthritic Supplements Antiarthritic AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant AMPA-Na Channel Blocker Anticonvulsant Tricyclic Antidepressant Antidepressant Tricyclic Antidepressant Antidepressant Tricyclic Antidepressant Antidepressant Mu Agonist Antidiarrheal Supplements Anti-inflammatory NMDA-Ca Channel Blocker Antitussive Supplements Antoxidant Gaba Agonist Benzodiazepine Anti-inflammatory Corticosteroid Increase Blood Flow Hemorheologic Alpha II-Agonist Hypotensive Calcium Channel Blocker Hypotensive Alpha II-Agonist Hypotensive Gaba Agonist Muscle Relaxant NMDA-Ca Channel Blocker Muscle Relaxant Supplements Muscle Relaxant Supplements Muscle Relaxant Anti-inflammatory Anti-inflammatory Anti-inflammatory Anti-inflammatory Mu Agonist Mu Agonist Notes: Ketamine 5%, Gabapentin 10%, Clonidine 0.2%, Baclofen 2% is standard starting regimen. (Formula # 7919) Refernces: 1.Jones M. Chronic Neuropathic Pain: Pharmacological Interventions in the New Millenium - A Theory of Efficacy. International Journal of Pharmaceutical Compounding . Jan/Feb 2000; 4(1): 6-15. 2. Jones M. Clinical Nuggets and Pearls: Chronic Neuropathic Pain and Opioid Tolerance. International Journal of Pharmaceutical Compounding. Jan/Feb 2002; 6(1): 4-6. Algorithm for Chronic Neuropathy
Mode of Action and members of the class (not exhaustive) 1) NMDA-Ca Channel Blocker
Ketamine 5-10% in PLO, 10-30mg PO or PR tid regularly + up to q2h prn
Orphenadrine 10% in PLO or 100mg PO tid Dextromethorphan 10% in PLO or <400mg/day PO Amantadine 200mg/250-500cc IV over 3 hours once (repeat x1 prn).
Anticonvulsant - * Gabapentin 6-10% in PLO tid + up to q2h prn
or up to 2-3Gm/day PO *Probably blocks glutamate at the NMDA also
Carbamazepine 10% in PLO tid + up to q2h prn
or 100mg-200mg PO bid/tid (Max 800mg/day)
Antiarrhythmic - Lidocaine 5-10% in PLO tid + up to q2h prn
Mexilitine 2% in PLO tid + up to q2h prn
Clonidine 0.2% in PLO tid + up to q2h prn
MU agonists (MS, Hydrocodone, Oxycodone, etc) (low dose) PO or PLO
Mu Agonist also: Loperamide 7% and up PLO 5) GABAb Agonist Baclofen 2% PLO tid + up to q2h prn
Non specific GABA agonist - Klonopin 0.5mg-1mg SubL. qhs
6) Tricyclic Antidepressant Desipramine 2-10% in PLO tid + up to q2h prn or 25-100mg PO qHS
Amitriptyline 2-10% in PLO tid + up to q2h prn
Magnesium: Intracellular Resident NMDA Ca Channel Blocker
For Fibromyalgia - Mg/Malic Acid 25/250 mg PO tid
For Diabetic Neuropathy - Lipoic Acid 100mg-300mg PO tid
Bioflavanoids/citrus 500 to 2000 mg PO tid
Nifedipine 2 to 5% PLO tid Or up to 16% for small areas, i.e., toes Alpha-antagonist (I & II) Phentolamine 80mg over 24 hours slow IV one time only! (for organic neuropathy, i.e., pancreatic cancer).
1. Ketamine 10%, Gabapentin 6%, Clonidine 0.2% is standard starting regimen. 2. Add Baclofen 2%, Amitriptyline 2%, Nifedipine, Opioid, Mg as needed. (I.e., use
Baclofen specifically in FM patients but also in others and use Amitriptyline in CRPS Type I patients but also in others.)
3. In allodynic Post Herpetic Neuralgia use Ketamine 10% + Bupivacaine 0.5% in a
Normal Saline spray to the area, wait 5 to 10 minutes and apply the PLO gel chosen. This spray also has been reported to ease burn pain.
4. Evidence exists for presence of NMDA receptors in the dermal-epidermal junction.
AMPA receptors always lie close to NMDA receptors.
5. Evidence exists for the presence of Gabapentin receptors in the periphery. 6. Evidence exists for the presence of adrenergic receptors in the periphery. 7. Evidence exists for the presence of opioid receptors in the periphery.
References:
1. Jones M. Chronic Neuropathic Pain: Pharmacological Interventions in the New
Millennium – A Theory of Efficacy. International Journal of Pharmaceutical Compounding. Jan/Feb 2000; 4(1): 6-15.
2. Jones M. Clinical Nuggets and Pearls: Chronic Neuropathic Pain and Opioid Tolerance.
International Journal of Pharmaceutical Compounding. Jan/Feb 2002; 6(1): 4-6.
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Algorithm for Chronic Neuropathy 
Magnesium: Intracellular Resident NMDA Ca Channel Blocker
For Fibromyalgia - Mg/Malic Acid 25/250 mg PO tid
For Diabetic Neuropathy - Lipoic Acid 100mg-300mg PO tid
Bioflavanoids/citrus 500 to 2000 mg PO tid
Nifedipine 2 to 5% PLO tid Or up to 16% for small areas, i.e., toes Alpha-antagonist (I & II) Phentolamine 80mg over 24 hours slow IV one time only! (for organic neuropathy, i.e., pancreatic cancer).
1. Ketamine 10%, Gabapentin 6%, Clonidine 0.2% is standard starting regimen. 2. Add Baclofen 2%, Amitriptyline 2%, Nifedipine, Opioid, Mg as needed. (I.e., use
Baclofen specifically in FM patients but also in others and use Amitriptyline in CRPS Type I patients but also in others.)
3. In allodynic Post Herpetic Neuralgia use Ketamine 10% + Bupivacaine 0.5% in a
Normal Saline spray to the area, wait 5 to 10 minutes and apply the PLO gel chosen. This spray also has been reported to ease burn pain.
4. Evidence exists for presence of NMDA receptors in the dermal-epidermal junction.
AMPA receptors always lie close to NMDA receptors.
5. Evidence exists for the presence of Gabapentin receptors in the periphery. 6. Evidence exists for the presence of adrenergic receptors in the periphery. 7. Evidence exists for the presence of opioid receptors in the periphery.