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MEDICATION Section 7 of 11
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Muscle relaxants (eg, Flexeril, Soma, Robaxin, Parafon forte) are options to help decrease muscle tightness and restriction, thereby facilitating conservative treatment with exercise and manipulation. Tizanidine (Zanaflex) is being used for muscle tension cephalgia and may hold promise for TOS.
Anti-inflammatory medication can decrease irritability and pain and enhance conservative treatment results. Long-acting preparations often are most effective and are tolerated better (eg, Relafen, Daypro, Celebrex). Voltaren or Arthrotec and Celebrex are relatively long-acting alternatives that are less irritating to the GI tract than Naproxen or Clinoril.
Some internists or rheumatologists may recommend vasodilators and calcium-channel blockers, if significant vascular and vasoconstrictive involvement exists. These agents are not primary drugs of choice for TOS but should be considered ancillary or secondary options to be considered and integrated into treatment as clinically indicated.
Drug Category: Muscle relaxants -- Used to relax and loosen the tight musculature involved in TOS, facilitate stretching and manipulation treatments, relieve pain, and assist with sleep. Drug Name
Cyclobenzaprine (Flexeril) -- Muscle relaxer of moderate duration, centrally acting, related to TCAs chemically. This drug often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Adult Dose 10 mg tid PO; 20-30 mg before hs may be necessary, and taking only 5 mg (half a tab) bid/tid (in addition to hs dose) may be less sedating and better tolerated during daytime; not to exceed 60 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; have taken MAO inhibitors within the last 14 d; cardiac conditions; hyperthyroidism
Interactions Coadministration with MAO inhibitors and TCAs may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine; may block antihypertensive action of some medications, like guanethidine; may enhance seizure risk in patients taking tramadol (Ultram); atropinelike actions
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in patients with angle-closure glaucoma and urinary hesitance; use of anticholinergic medications; avoid operating machinery
Drug Name
Carisoprodol (Soma) -- Short-acting medication that works at spinal cord level.
Adult Dose 350 mg PO tid/qid
Pediatric Dose Not established
Contraindications Documented hypersensitivity; acute intermittent porphyria
Interactions Increases toxicity of alcohol, CNS depressants, MAO inhibitors, clindamycin, phenothiazines
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in renal and hepatic impairment; psychologic dependence, abuse, and possible withdrawal symptoms may occur
Drug Name
Methocarbamol (Robaxin) -- Short-acting muscle relaxer that probably works through CNS mechanisms.
Adult Dose 750-1500 mg PO tid/qid; not to exceed 8 g/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; renal impairment
Interactions May cause color interference with screening tests for 5-HIAA and VMA
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in patients with history of seizures
Drug Name
Chlorzoxazone (Flexaphen, Paraflex, Parafon Forte) -- Short-acting muscle relaxer, working via central pathways (spinal cord and subcortical).
Adult Dose 250-500 mg tid/qid up to 750 mg tid/qid
Pediatric Dose 20 mg/kg/d or 600 mg/m 2 /d tid/qid
Contraindications Documented hypersensitivity; hepatic impairment
Interactions Increases toxicity of CNS depressants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Rare idiosyncratic and unpredictable hepatocellular damage, possibly fatal; may cause tachycardia and tightness in chest
Drug Category: Nonsteroidal anti-inflammatory drugs -- Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Drug Name
Nabumetone (Relafen) -- Nonacidic NSAID rapidly metabolized after absorption to a major active metabolite that inhibits cyclo-oxygenase enzyme, which in turn inhibits pain and inflammation.
Adult Dose 1-2 g PO qd
Pediatric Dose Not established
Contraindications Documented hypersensitivity; active peptic ulceration, hepatic impairment
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Category D in third trimester of pregnancy; elderly patients may require lower doses; caution in hepatic and renal impairment
Drug Name
Oxaprozin (Daypro) -- For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult Dose 600-1200 mg PO qd; not to exceed 1800 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity, history of GI disease, cardiac failure, renal or hepatic dysfunction, bleeding disorders
Interactions Increases toxicity of anticoagulants, aspirin, and diuretics
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions May cause dizziness, indigestion, nausea, and abdominal cramps
Drug Name
Celecoxib (Celebrex) -- Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult Dose 200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
Drug Name
Rofecoxib (Vioxx) -- On September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of rofecoxib (Vioxx) from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo.
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of rofecoxib for each patient.
The suspension dose, 12.5 mg/5 mL or 25 mg/5 mL, may be substituted for 12.5- or 25-mg tabs, respectively.
Adult Dose 50 mg PO qd; subsequent doses are 50 mg qd prn; use for >5 days in management of pain not established; tablets may be taken with or without food
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with fluconazole may cause increase in rofecoxib plasma concentrations because of inhibition of rofecoxib metabolism; coadministration of rofecoxib with rifampin may decrease rofecoxib plasma concentrations
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
Alert: On September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of rofecoxib (Vioxx) from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo.
A major FDA study of rofecoxib found an apparent 3-fold increase in the risk of sudden cardiac death or heart attack among patients who had taken higher doses of the drug compared to the risk of patients who had not recently received similar medication. The report showed that even patients taking the standard starting dose of 12.5 mg or 25 mg of rofecoxib had a 50% greater chance of heart attack or sudden cardiac death than patients on any dose of celecoxib (Celebrex). The large-scale study was conducted after analyzing the medical records of 1.4 million people insured by Kaiser Permanente in Oakland, Calif, between 1999-2001.Note: The study has inherent limitations in that it is observational, rather than randomized and
controlled.
Drug Name
Naproxen (Anaprox, Naprelan, Naprosyn) -- For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Drug Name
Sulindac (Clinoril) -- Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Adult Dose 150-200 mg PO bid or 300-400 qd; not to exceed 400 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; patients whom aspirin, iodides or other NSAIDs induce hypersensitivity; gastrointestinal (GI) bleed, and renal insufficiency
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia; caution in anticoagulation defects or are receiving anticoagulant therapy
Drug Name
Diclofenac (Voltaren, Cataflam) -- Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Adult Dose 25 mg PO bid/tid
If well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response is obtained or total daily dose of 150-200 mg is reached
Higher doses generally do not increase effectiveness
Pediatric Dose <12 years: Not established
>12 years: Administer as in adults
Contraindications Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and those at high risk of bleeding
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
Drug Name
Diclofenac and misoprostol (Arthrotec) -- Diclofenac inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Misoprostol is prostaglandin analog that protects lining of GI tract by replacing depleted prostaglandin E1 in prostaglandin-inhibiting therapies.
Adult Dose 1 tab PO bid/tid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy X - Contraindicated in pregnancy
Precautions Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low white blood cell counts occur rarely, and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if there is persistent leukopenia, granulocytopenia, or thrombocytopenia
Hi my experience is that of much narcotics as prior to surgery I was on over 200mg of morphine. I then had surgery to remove my 1st rib and am blessed with a cervical rib........hence it to say I have again become symptomatic.......so I use zanaflex.( is used for MS)..depends on the pain.....if it is nerve go with the lyrica....if muscle go with the others.......was prescribed 8mg three times a day and am actually taking 1mg-2 mg ever three hours as well as lyrica. I am not sure why u choose not to use neurontin, but lyrica is a better new drug ....despite weight gain....however I am on 150mg of it and have gained no weight....little tummy but always been an issue still a size 6 and was a 12 while on narcs.....not sure what will work best but the ONLY thing that takes the muscle pain away is Diazepam.....Vallium.....it works!!!!!!!!!!!!!!
I am not sure if this helps you, but checkout the article I posted the link and info for as this is what I took to my doctor. I must say I am a nurse and ask my doctor for the meds I need.
Any questions please feel free to PM me!
take care and good luck
Sincerely,
Victoria
ps for the constipation eat lots of prunes dates and colace helps as well as sennokot but I am sure u are aware of this by now.
Victoria