Drug Interactions??
 

So...in an attempt to try to manage my pain, my pain doctor is taking me off Lyrica and is putting me on Cymbalta. The pharmacy wouldn't fill the script initially because of "drug interactions" and they needed to check with the doctor. They have now filled the script...but I haven't started it yet.

I looked up the possible interactions and I am a little worried about starting these new meds (not to mention a little miffed that the doctor didn't mention this when she changed my meds so that I could talk to her about it). My biggest concern isn't the fact that there might be an interaction...my concern is that I wouldn't know if there was because all the symptoms for this possible interaction are what I already have...and it can be a fatal condition. So all my warning signs for this possibility are shot and the doctor only wants to see me once every two months.

Why do I just feel like I have the worst luck with doctors? Or is this sort of thing just normal? Am I probably just worrying over nothing? I'm going to discuss with my primary doctor Friday when I see her before I start the Cymbalta. Anyone have any experience with Cymbalta? The major interaction is between that and the Tramadol. They also say in the commercial that there are risks with Cymbalta and NSAIDS and I am taking NSAIDS...but I didn't see that listed under the drug interactions that I looked up.

If anyone has any information or experience with this, I'd love to hear about it. Thanks!

I dont think there is anything to worry about...
 

I know so many people that take cymbalta and lyrica at the same time inculding myself a few years back and I had no problems. The combination of Cymbata and lyrica/neurontin is a great combo for rsd. :) I take cymbalta an tramadol, and the pharmisist tells me that and i say i have been taken them for months with no problems. I wouldnt be afraid to take them. You will never know until you take them and the doctor wouldnt give them if he didnt feel that it was safe! :) I am no doctor, I just speak from experience from myself and others that are on those same meds with no problems!

Alot depends on the dose of Tramadol used. Tramadol has some serotonergic potential and can be additive with SSRIs. Cymbalta is a mixed SSRI + SSNI product.

Here is a drug checker:

http://www.drugs.com/drug_interactions.html

Another good resource is www.rxlist.com for details on most common drugs used today. Use Ultram for the search on tramadol there.

That's good to know that you take them both with no bad interactions. My big concern I guess is that if there was a problem, how would I or the doctor know since I already have all the serious symptoms that you are supposed to look for? But I guess we do have to trust that our doctors know what they are doing.

Thanks for the links!

How are you doing on the cymbalta? Did you get all of the drug interactions worked out?

Not so good...sad to say. The solution from the pharmacy was to NOT fill the Tramadol so I am off that now. And the cymbalta does NOT seem to agree with me AT ALL. I started taking it last Friday and 30-45 minutes after I take it I get violently sick. I was already having problems with vomitting but this hits me SO much worse and it is like clockwork. I have tried taking it with food, without food, with my other meds, seperately from the other meds...nothing seems to change the fact that I get violently ill. Today I actually started choking (lasted about 30 seconds) while I was sick so now I am actually scared. On top of which the pain is significantly worse than it was before...though not sure if that's because the meds don't work or because I can't keep them down. Either way...if it's the cymbalta making me sick then it doesn't matter.

Oh well...trial and error continues...

Hello again. Sorry to hear what you are going through. You say the "trial and error continues." Forgive me, but that seems about right.

In essence, I think you're being treated for fibromyalgia or a peripheral neuropathy, but not CRPS, whether you've been let in on this bit of information or not. If I may, the proper name for Cymbalta is Duloxetine. And if you run a PubMed search for "Tramadol Duloxetine," you'll get 34 hits, almost all of them dealing with fibromyalgia or peripheral neuropathies. And of the 34 articles, only four are freely available through "PubMed Central," and then only three are in English:

Fibromyalgia: presentation and management with a focus on pharmacological treatment, Sumpton JE, Moulin DE, Pain Res Manag. 2008 Nov-Dec; 13(6):477-83, ONLINE TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...f/prm13477.pdf

Management of fibromyalgia syndrome--an interdisciplinary evidence-based guideline [Behandlung des Fibromyalgiesyndroms – eine interdisziplinäre S3-Leitlinie], Häuser W, Arnold B, Eich W, et al, Ger Med Sci. 2008 Dec 9; 6: Doc 14, ONLINE TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti.../GMS-06-14.pdf

Effects of treatments for symptoms of painful diabetic neuropathy: systematic review, Wong MC, Chung JW, Wong TK, BMJ 2007 Jul 14; 335(7610): 87, Epub 2007 Jun 11, ONLINE TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...s-00087-el.pdf

And what do each of them suggest by way of pharmacological therapies? With minor variations it's (1) Duloxetine (Cymbalta) ("FDA-approved indication for fibromyalgia"), (2) Tramadol and (3) Gabapentin (Neurontin) or Pregabalin (Lyrica). Sound familiar?

What sticks out here is the universality of Tramadol, whereas RSD/CRPS patients are treated with a host of opioids, most of us blowing through Ultram (Tramadol) in a few weeks on our way to much harder sauces. And the funny thing is that Tramadol has a particularly bad rap with nausea. By way of example, if you compare the FDA approved Prescribing Information sheets for oxycodone and Ultram, you'll see that oxycodone is associated with nausea in less than 3% of those participating in trials, while nausea with is dose-dependent with Tramadol, ranging from 15.1 to 26.2%!!! Compare, http://pain-topics.org/pdf/PI/PI_Oxy...blets-30mg.pdf with, http://www.ortho-mcneil.com/ortho-mc...r.pdf#zoom=100.

In fact, there's a whole sub-industry devoted to combining Tramadol with Acetaminophen (Tylenol or Paracetamol in the U.K) just to cut down on the side-effects of Tramadol, primarily nausea. See, e.g., Tramadol/paracetamol combination tablet for postoperative pain following ambulatory hand surgery: a double-blind, double-dummy, randomized, parallel-group trial, Rawal N, Macquaire V, Catalá E et al, J Pain Res. 2011 Apr 8; 4:103-10, ONLINE TEXT @ http://www.ncbi.nlm.nih.gov/pubmed/21559356:

Adverse events (mainly nausea, dizziness, somnolence, vomiting, and increased sweating) occurred less frequently in patients under combination treatment (P = 0.004).

So if your doctors aren't going to give you oxycodone, why not cut the Tramadol with a little of your old friend, Tylenol? [In the U.S., the product is marketed under the trade-name Ultracet.] I would submit it's because they are slavishly adhering to the Groupthink on treating fibromyalgia and/or peripheral neuropathies. To the letter, thank you.

So, unless you have already done so, can't you please just get an ASAP consultation with Timothy Lubinow, MD at Rush, just in the name of a second opinion on CRPS? I'm on bended knee on this one, where all of the evidence suggests that no one's changes of going into permanent remission on ketamine improve over time, to put it mildly, but I think we've been over that ground before.

Please.

Mike

"why not cut the Tramadol with a little of your old friend, Tylenol? [In the U.S., the product is marketed under the trade-name Ultracet.]"

Hi, in what way does the tylenol enhance the tramadol?
cheers

In the US, historically Tylenol has been used in combination with other pain relievers.

Tylenol with Codeine
Tylenol with oxycodone (Percocet)
Tylenol with Darvon (Darvocet)

In OTC products Tylenol with just about EVERYTHING.

This is now changing as the US FDA is trying to cut Tylenol mixtures completely off the approval lists.

In the past Darvocet was released when the patent for Darvon expired. The same is true for Ultracet. It did not come on the market until Ultram went generic.

While it might be true that mixing Tylenol with tramadol results in more efficient pain relief, I think it is just basically a marketing ploy. Drug companies do this all the time with their drugs, even to the point of massaging data in studies to get the FDA to approve the new mixture.

We are seeing a change in the US about this trend with Tylenol. And in fact it may even result with some OTC brands including Tylenol Extra strength 500mg tabs being removed from the OTC market in the future and becoming RX only.

Ultram was a huge money maker for McNeil when it came out. Going generic really was painful for them. Adding their own Tylenol to make a new product restored a lucrative situation to their balance sheets!

As far as the nausea issue...all opiates cause nausea. I received far more complaints about nausea side effects than I ever did regarding Tramadol (which was never). Opiate nausea may occur when doses are too high for that particular patient, and dose adjustments often take care of them.

The nausea of Tramadol is different IMO and more connected to the serotonin actions of this drug. SSRIs are also reported high in nausea when first starting them.

And it is correct that Tramadol is recommended for Fibro patients specifically. This is because some studies show that the pain receptors for opiates are blocked by high endogenous endorphins in this disorder. I saw this mentioned at a chronic pain seminar during the Fibro portion. Opiates are no longer being recommended for Fibro patients for this reason. Also opiates have a checkered past for not working well for peripheral neuropathies.

When I was given Tramadol last year, I had one brief episode of nausea at the 50mg dose level, that lasted briefly...about 30 minutes. I haven't had any recurrance of that since. I don't take Tramadol every day, and only use it on very bad nights in fact with no further problem.

I worked many years in night shifts and never once had a nausea question regarding Tramadol. But nausea with opiates? Very very common.