![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 9 to 33 of 48. Go back in thread:
Posted by Larry Hoover on March 17, 2005, at 20:56:19
In reply to Re: Percocet » Larry Hoover, posted by ed_uk on March 16, 2005, at 12:32:16
> Hi Larry,
>
> Do you use 5/325 oxy/acet or 5/500? I don't really like 'fixed dose' opioid/acetaminophen products, there's not much room for dose titration. If you need a high dose of oxycodone, you overdose on acetaminophen. If you only need a small amount of oxycodone, you get dose of acetaminophen which is likely to be sub-therapeutic.Good point. I checked the formulary. There are all sorts of oxycodone products that don't have acetominophen or acetylsalicylic acid in them.
> Could you encourage your doc to prescribe acetaminophen and oxycodone separately? You could take 1g acetaminophen up to four times a day prn + a variable dose of oxycodone 4-6 times a day. Is oxycodone IR called Supeudol in Canada?
No, it's called oxycodone IR. Seriously.
> If it's difficult to get acetaminophen and oxycodone separately, it might be useful to get a prescription for some 5/325 pills *and* some 5/500 pills. You could take up to three 5/325 pills for severe pain or up to two 5/500 pills for less severe pain. If you need less oxycodone than this (eg one 5/500 pill) you could take a 'plain' acetaminophen tablet in addition. Hmm, I've just realised that Percocet probably comes in lots of different 'strenghts' in Canada that I don't know about. Never mind.You made the point....best to have oxycodone straight up. I can easily manage the NSAID dose on my own.
> I know this is all obvious really but I thought I'd post anyway :-S I hope you doing think I'm being rude by posting these things, you probably do all these things anyway.Just never gave any thought to oxycodone tablets themselves.
> >Taking a half tablet every two hours is the same total dose as one tablet every four hours, but the blood concentration does not oscillate as much.
>
> Do you mind dosing so frequently?No. I only do it when I'm in a pain flare, and that kind of distorts time anyway. It's all about the pain.
> Have you ever taken a low dose of OxyContin + regular acetaminophen + oxycodone IR for breakthrough pain. I suppose since you'd be taking the acetaminophen so frequently the OxyContin wouldn't increase convenience that much.
Well, Oxycontin would be good for maintaining a more stable oxycodone blood concentration, but I doubt my doctor would go that route.....this is a Worker's Comp case, and you would have to know just how much bureaucracy is involved to get any narcotics....this is now 14 months post-injury. Still waiting for surgery.
> I don't know what schedule oxycodone is in Canada, I don't know anything about your schedules to be honest. In the UK, oxycodone's always schedule 2, even when it's combined with acetaminophen, which is probably why they haven't bothered marketing any oxycodone/acetaminophen combinations here. If Percocet was available, it would never be a popular as co-codamol 30/500, which is schedule 5! Schedule 5 drugs have very few restrictions, schedule 2 drugs have the full controlled drug requirements, not that they make much difference to the patient. Certain doctors seem to live in some kind of strange fantasy land where schedule 5 opioids like dihydrocodeine tabs are much safer than schedule 2 drugs like oxycodone! I suppose many doctors are just afraid of looking suspicious, I worry that it has a bad impact on pain control - people being given inadequate doses etc.
I don't think there's as much differentiation between narcotics here. I honestly don't know, though.
> >I find that Percocet with Toradol (keterolac tromethamine) is a very effective combination.
>
> Do you respond well to any other NSAIDs? I'm a bit suspicious of ketorolac!The only thing about keterolac that scares the bejeezuz out of me is the list of adverse reactions. It doesn't work so well on its own, but with oxycodone, it's golden. I don't know why. I stumbled on the combo when I was trying to augment the Percocet. Ketoprofen, ibuprofen, naproxen, some less well known prescription NSAIDS (forget the names), turmeric, I was throwing anything in there to see what would work. Keterolac came through a winner.
BTW, turmeric is the absolute best COX-type med I've ever used. Beats Vioxx, Mobicox, Celebrex....works better, lasts longer, and costs pennies a dose.
> Scroll down to table 5 for a comparison of NSAIDs. Table 2 is also interesting. Perhaps you take an anti-ulcer drug, or only take ketorolac occasionally.
Ya, I don't wanna get a bleed. I try to be careful.
> http://www.jr2.ox.ac.uk/bandolier/booth/painpag/nsae/nsae.html#Heading10
>
> Table 5 is called 'Relative risk of gastrointestinal complications with NSAIDs, relative to ibuprofen or non-use'.
>
> I take it you've tried ibuprofen and it wasn't good, have you tried up to 2400mg/day?Ya, that's my fallback behind keterolac. When it isn't as bad.
> I always wonder whether ibuprofen is really any safer that other NSAIDs or whether its apparant safety is simply a reflection of the tendency to prescribe it at relatively small doses for mild/moderate pain compared with other NSAIDs which tend to be prescribed at comparatively high doses for the treatment of severe pain in rheumatoid arthritis etc.You know what? I don't worry about GI bleeding when I'm in pain....other than by taking with food. People suing over Vioxx adverse effects.....they'd rather be in pain? Ya, right. Sue God for that.
> Best regards,
> Ed.You too. Thanks for the support.
Lar
Posted by Larry Hoover on March 17, 2005, at 21:00:28
In reply to Re: Percocet » Larry Hoover, posted by ed_uk on March 16, 2005, at 12:32:16
> Hi Larry,
>
> http://www.jr2.ox.ac.uk/bandolier/booth/painpag/nsae/nsae.html#Heading10P.S. I've used that page to show that NSAID bleed deaths exceed deaths from self-injury (in opposition to those who argue that antidepressants lead to such deaths.....NSAIDS kill more than all self-harm combined).
Lar
Posted by cubbybear on March 18, 2005, at 5:00:44
In reply to Re: Analgesics » cubbybear, posted by ed_uk on March 17, 2005, at 12:35:47
> >shoulder injury that I sustained in a fall 6 weeks ago.
>
> Do your doctors have any idea how quickly it might heal?No one can ever say exactly since everyone is different. Also, the orthopedist has not taken an MRI (yet) so his diagnosis is based on a basic physical exam, manipulating the joint, etc. He said about 3 wks. ago that it could be a month or more, but I say, no way. I think it could be many months, judging on the (near) lack of progress over the past 6 weeks and reading/hearing elsewhere that shoulder injuries can take many months to heal. My biggest fear is being told that I'll need surgery--not least of which is because I'm taking Parnate and that raises all sorts of issues vis a vis anaesthesia.
>
> What type of damage have you done to your shoulder?Again, based solely on a non-MRI exam, he says it's a ruptured bicepital tendon. Don't know the extent of it without an MRI, or if anything else got torn. A sonogram revealed no fractures or bone abnormalities.
>
> Do you have pain at rest or only on movement? Perhaps you have pain at rest which gets worse on movement.No, there's never pain at rest, but only during certain movements, such as bringing the arm up and out to a horizontal or vertical position. Getting up in the morning is the absolute worst since we naturally move our arms into these positions while we sleep. Also I have three different KINDS of pain including pain from the original injury, plus pain that seems like it's muscle spasms plus something else occasionally, which feels like clicking inside the shoulder joint--a very common symptom of this kind of injury.
>
> >Several different meds did nothing to help.
>
> What have you tried so far? What doses?Keep in mind that I live in Thailand and the names might be different:
a) Voltaren --NSAID pills, generally as needed, at most 50-100 mg/day
b) Myonal--muscle relaxant --as needed about 50-100 mg. day
c) Neurontin-used mostly as a sleeping aid , as needed 100 mg./day, not every day.
You can see that I've been taking these meds very conservatively. Perhaps Id have better results if they were taken at full dose on a daily basis, but so far I don't want to overdo it with the NSAID (risk of gastrointestinal problems) nor with the Neurontin.
>
> >I've had 2 sessions this past week and, so far so good.
>
> It sounds very promising :-)
I'm holding forth a conclusion on the acupuncture for at least another week or so, but thanks for your good wishes anyway.cubbybear
Posted by cubbybear on March 18, 2005, at 5:36:58
In reply to Re: Percodan/Percoset Experiences?? » cubbybear, posted by Larry Hoover on March 14, 2005, at 11:31:23
>
> I regret to acknowledge that I have had some lengthy interactions with Percocet. Not because of the drug, but because of the necessity for it. Pain. Chronic pain sucks.
>
> Hi Larry,
In a subsequent post, you mentioned that your problem is a worker's comp case. Can you say what happened to cause your injury?
cubbybear
Posted by Larry Hoover on March 18, 2005, at 7:15:09
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover, posted by cubbybear on March 18, 2005, at 5:36:58
> >
> > I regret to acknowledge that I have had some lengthy interactions with Percocet. Not because of the drug, but because of the necessity for it. Pain. Chronic pain sucks.
> >
> > Hi Larry,
> In a subsequent post, you mentioned that your problem is a worker's comp case. Can you say what happened to cause your injury?
> cubbybearI fell off a truck.
My upper arm bone (humerus) cracked the end of one of my forearm bones, the radius. Originally diagnosed as a non-displaced fracture (broken, but all pieces still where they ought to be), treatment was conservative. Upon load-bearing work in physiotherapy, the joint began to lock, with excrutiating ice-pick point pain. I had to discontinue physio.
Also, the fall did nerve damage on the other side of elbow, at the ulna. The compression fracture on the outside aspect of my arm was accompanied by extension ligament damage on the inside. (In effect, my elbow "tried" to bend sideways.) That also caused a significant nerve injury to the ulnar nerve, which ennervates the pinky, and one-half of the ring finger (split right down the middle, freakily enough), the associated part of the palm, and a decent patch of the forearm. When you "hit your funny bone", you've hit the ulnar nerve where it passes through the ulnar groove, a small depression in the end of the ulna. (Kind of like the carpal tunnel, the ulnar groove allows the nerve to get past skeletal structures that would otherwise block the way.)
Upon the onset of this locking phenomenon, I was told I clearly had a "surgical elbow". That was last March. Worker's Comp wanted evidence. CT and MRI were inconclusive. WC insisted I see their own choice of surgeon.
While waiting for all this to happen, an achiness came into play, along with the ice pick pain. I was in pain 24/7. When I finally got to see this surgeon (55 weeks post-injury), I was really quite tender. His examination didn't make me hurt on the spot, but by the time I drove home (2 hours), I was in agony. Not only did I have a major flare of the ice pick and the ache, but the nerve injury had been massively exacerbated, feeling like that "funny bone" thing, all the time. So, I seem to have musculo-skeletal pain, hyperalgesic pain (the ache, a response to steady pain signals arriving at the spinal cord), and neurogenic pain (the ulnar nerve thingie), all at the same time.
BTW, for the major surgical consult, I had to get new x-rays, and collect together all the older imaging studies. As I had them at home for a few days prior, I took a look at them. It's clearly not a non-displaced fracture. Even I can see that. I've got an exposed jagged edge on the radial head, and lord knows what damage that has been doing to the cartilage during this period of delay.
Bureaucracy sucks.
Lar
P.S. This is not my first nor only experience of serious pain. Merely the most recent/most salient.
P.P.S. I still have yet to be booked for surgery.
Posted by ed_uk on March 18, 2005, at 7:23:07
In reply to Re: Percocet » ed_uk, posted by Larry Hoover on March 17, 2005, at 20:56:19
Hi Lar!
>oxycodone IR
Can you get a prescription for this?
>You made the point....best to have oxycodone straight up. I can easily manage the NSAID dose on my own.
Lol sorry, I know you can!
>Ketoprofen, ibuprofen, naproxen, some less well known prescription NSAIDS...
Have you tried diclofenac? - it's probably the most popular NSAID here.
>BTW, turmeric is the absolute best COX-type med I've ever used.
It works even better than ketorolac?
>Ya, I don't wanna get a bleed. I try to be careful.
If you're needing ketorolac a lot, you could always go on lansoprazole 30mg or another PPI.
>People suing over Vioxx adverse effects.....they'd rather be in pain? Ya, right. Sue God for that.
IMO, Vioxx shouldn't have been discontinued, I'm really not convinced that rofecoxib is any more dangerous than etoricoxib or valdecoxib. COX-2 inhibitors can still be useful for people at high risk of serious GI toxicity who are at a low risk of cardiovascular/cerebrovascular events.
http://medicines.mhra.gov.uk/ourwork/monitorsafequalmed/safetymessages/ddlcox2170205.pdf
-Ed
Posted by ed_uk on March 18, 2005, at 7:29:22
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover » cubbybear, posted by Larry Hoover on March 18, 2005, at 7:15:09
Hi Lar,
Does the Percocet/Toradol help your neuropathic pain? Have you tried anything else for the neuropathic pain?
/Ed
Posted by ed_uk on March 18, 2005, at 8:18:29
In reply to Re: Analgesics Shoulder injury » ed_uk, posted by cubbybear on March 18, 2005, at 5:00:44
Hi cubbybear!
>My biggest fear is being told that I'll need surgery--not least of which is because I'm taking Parnate and that raises all sorts of issues vis a vis anaesthesia.
Did you read my posts to ace about MAOIs/anesthesia? I posted a few days ago.
Some drugs used in anesthesia need to be avoided but others are safe, there are *many* myths surrounding MAOIs and anesthesia/drug interactions. Some of the drugs listed as interactions don't really interact at all!
Parnate may increase the incidence of hypotension during general anesthesia, the doses of drugs used to treat the hypotension would need to be carefully titrated. Some 'pressors' are best avoided, others are safe.
Pethidine (meperidine) and tramadol shouldn't be combined with MAOIs, there are many alternatives though, that's not an issue. You'd need to make sure that all the important interactions were written all over your drug chart!
I know it could be very difficult in Thailand though, I remember you saying that no one was knowledgeable about MAOIs. If you *could* find an anesthetist who was knowledgeable about MAOIs, you almost certainly wouldn't need to discontinue the Parnate.
>No, there's never pain at rest, but only during certain movements, such as bringing the arm up and out to a horizontal or vertical position.
Pain that occurs on movement (incident pain) doesn't usually respond well to opioids, including oxycodone and morphine. There are usually more effective alternatives :-)
>Voltaren --NSAID pills, generally as needed, at most 50-100 mg/day
We call it Voltarol here, we do use imported Voltaren though, it's common practice in the UK for pharmacies to import drugs from elsewhere in the European Union, especially Belgium, Spain and Greece - where drugs are sold more cheaply.
You'd probably need about 50mg diclofenac three times a day, this is a common for musculo-skeletal pain, a lower dose might be adequate if you are over 65. At 50mg 3x a day, some analgesia may appear straight away. If significant inflammation is present, the full effects can take up to three weeks to develop. Diclofenac is often a good choice for musculo-skeletal pain.
Did you have any side effects from Voltaren when you took it before? Have you asked your doctor whether it is safe to take a higher dose?
I see you are worried about gastric side effects.
Are you at high risk....1. Over 65.
2. History of peptic ulcers (stomach or duodenal) or bleeding of the gastrointestinal tract.
3. Takes a corticosteroid eg. prednisone, prednisolone.
4. History of H. Pylori infection, even if eradicated.
If any of the above apply to you, a gastro-protective drug would be advisable. Lansoprazole is a popular choice, I think it's called Prevacid in Thailand, we call it Zoton!If you don't want to take a higher dose of diclofenac, you could consider combining a low dose of diclofenac with a standard dose of acetaminophen (paracetamol).
>Myonal--muscle relaxant --as needed about 50-100 mg. day
I just looked this drug up: eperisone, I hadn't heard of it before, very interesting. It looks like it's only available in the Far East. It said the usual dose was 50mg three time a day. Is it helping?
Baclofen (Lioresal) can be a useful drug for severe muscle spasm. 5-10mg baclofen three times a day is a common dose for pain associated with injuries. As is the case with incident pain, pain due to muscle spasm doesn't usually respond that well to opioids.
Best regards,
Ed.
Posted by Larry Hoover on March 18, 2005, at 20:07:24
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover, posted by ed_uk on March 18, 2005, at 7:29:22
> Hi Lar,
>
> Does the Percocet/Toradol help your neuropathic pain? Have you tried anything else for the neuropathic pain?
>
> /EdActually, yes, it is most effective for that. I came upon the combination somewhat out of desperation, just trying things I had from past treatments.
I have an appointment with my doctor for next week, but like I said, there is a major bureaucratic resistance to overcome.
Regards,
Lar
Posted by cubbybear on March 19, 2005, at 6:12:15
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover » cubbybear, posted by Larry Hoover on March 18, 2005, at 7:15:09
Hi Larry,
Well, you sure gave me the scoop on the injury, and I suspect that what i've got is probably a Garden of Eden in comparison. I can only wish you the best in overcoming this horrendous ordeal.
In your case I suppose that the oxycodone and "heavy-duty" meds are all that are viable for the pain, but I was wondering if you' ve ever tried Neurontin and if so, can you assess if it's helpful in any way.
Posted by cubbybear on March 19, 2005, at 7:34:32
In reply to Re: Analgesics » cubbybear, posted by ed_uk on March 18, 2005, at 8:18:29
> Did you read my posts to ace about MAOIs/anesthesia? I posted a few days ago.
I had missed it, but just accessed it and printed it out. This is very helpful and I'll keep it if and when the time ever comes for surgery.
I also have had major concerns about going for a routine colonoscopy. If the dr. says that it could be done with local anaesthesia and a sedative, I will certainly go that route, rather than with major anaesthesia. In any case, I need as much accurate info on MAOIs/anaesthesia as I can get my hands on.
>
>
> > I know it could be very difficult in Thailand though, I remember you saying that no one was knowledgeable about MAOIs. If you *could* find an anesthetist who was knowledgeable about MAOIs, you almost certainly wouldn't need to discontinue the Parnate.I JUST got this brilliant idea--that if surgery were necessary, I would enlist the assistance of my psychiatrist (who obviously knows all about MAOIs) and put him in touch with the gastroenterologist (for colonoscopy) or orthopedist (for shoulder). There *are* many doctors who are familiar with MAOIs here; the more important issue, i guess, is whether the anaesthetists are knowledgeable and willing to work with an MAOI patient.
>
> >No, there's never pain at rest, but only during certain movements, such as bringing the arm up and out to a horizontal or vertical position.
>
> Pain that occurs on movement (incident pain) doesn't usually respond well to opioids, including oxycodone and morphine. There are usually more effective alternatives :-)Are you serious? Opioids might not be effective in my case? So what alternatives could there possibly be, that would also be compatible with Parnate?
>>
> You'd probably need about 50mg diclofenac three times a day, this is a common for musculo-skeletal pain, a lower dose might be adequate if you are over 65. At 50mg 3x a day, some analgesia may appear straight away. If significant inflammation is present, the full effects can take up to three weeks to develop. Diclofenac is often a good choice for musculo-skeletal pain.Well, this probably explains why I've concluded it's not effective. Since the pain is very much on/off, I've decided to use it as "really" needed, which means ,on some days not at all, and on other days, just once a day. Truthfully, I'm scared of the gastro-intestinal risks, although I'm in the low-risk category for NSAIDs.
>
> Did you have any side effects from Voltaren when you took it before?
None.Have you asked your doctor whether it is safe to take a higher dose?
Yes, but he said that in my case, I'd best cut it out after a max. of 2 months. (if used at full dose).
>
> I see you are worried about gastric side effects.
> Are you at high risk....
>
> 1. Over 65.
No--I'm 56
>
> 2. History of peptic ulcers (stomach or duodenal) or bleeding of the gastrointestinal tract.No
>
> 3. Takes a corticosteroid eg. prednisone, prednisolone.
'
No
>
> 4. History of H. Pylori infection, even if eradicated.No
>
> If you don't want to take a higher dose of diclofenac, you could consider combining a low dose of diclofenac with a standard dose of acetaminophen (paracetamol).I grew up on good old aspirin. Never heard of Paracetamol until I came to Thailand. Would a combo of Diclofenac and aspirin be as effective, do you think? (come to think of it, I've already tried diclofenac w/aspirin at low doses/as needed and saw no improvement)
>
> >Myonal--muscle relaxant --as needed about 50-100 mg. day
>
> I just looked this drug up: eperisone, I hadn't heard of it before, very interesting. It looks like it's only available in the Far East.It's made in Japan. Don't know why the distribution is seemingly limited.
It said the usual dose was 50mg three time a day. Is it helping?
Again, my very conservative use of the meds may have led me to believe it's not helpful. I've tried taking it solely as needed, nowhere near the the maximum dose. The website info seems to show little risk of (long-term) side effects with Myonal, so I'd consider upping the dose a lot sooner than I'd do so with the NSAID.
>
As is the case with incident pain, pain due to muscle spasm doesn't usually respond that well to opioids.
>
Can't believe it! After all the posts and info I've been reading, to learn this is quite a surprise.My plans are these:
1) Continue with 2-3x per week acupuncture for another week or two and assess efficacy. If I see no improvement,2) Consult again with orthopedist to discuss medications, including increased doses of Myonal, low-dose oxycodone, cortisone injection, MRI, etc.
Something tells me that an MRI would be a very good idea at this point, to tell me exactly what damage was done to the tendon, so we could get a more educated prognosis.
Meanwhile, thanks loads for all your help and sharing your knowledge.cubbybear
Posted by ed_uk on March 19, 2005, at 14:24:13
In reply to Re: Analgesics » ed_uk, posted by cubbybear on March 19, 2005, at 7:34:32
Hi Cubbybear!
>I also have had major concerns about going for a routine colonoscopy. If the dr. says that it could be done with local anaesthesia and a sedative, I will certainly go that route, rather than with major anaesthesia.
Standard practice in the UK is to give an IV sedative, usually midazolam (Hypnovel, Versed) and an opioid, often pethidine (meperidine, Demerol). You must *not* let them give you any pethidine/meperidine!!!
IV midazolam or on its own would probably provide adequate sedation, it might cause a drop in blood pressure if the dose was excessive. If midazolam causes an excessive drop in blood pressure, an antidote is available - flumazenil. Certain blood pressure elevating drugs such as ephedrine are not safe for patients taking MAOIs.
>local anaesthesia
Some gastro-enterologists use lidocaine (lignocaine, Xylocaine) ointment to numb the anus.
>major anaesthesia
General anesthesia isn't commonly used for colonoscopy. If the colonoscopy is first attempted under sedation but it fails due to pain, general anesthesia may be recommended. Also, if someone is too anxious to have the procedure while they are awake, general anesthesia may be used.
For pain relief during colonoscopy, opioids are commonly given. Pethidine/meperidine is one of the most dangerous opioids for patients taking an MAOI, this is because the combination can cause the serotonin syndrome - this is because pethidine/meperidine acts as a serotonin reuptake inhibitor, a bit like an SSRI!
Other opioids which you should avoid include... tramadol, propoxyphene (dextropropoxyphene) and pentazocine. Low doses are morphine generally seem to be ok although some patients have become oversedated and required the opioid antidote naloxone (Narcan).
Since the data on the interaction between *other* opioids and Parnate is limited, it would probably be safest to perform the procedure using IV midazolam *alone*. If an opioid was necessary, morphine would probably be ok but the interaction has not been well studied.
From dr bob's tips...
'Having observed severe hypertension when an elderly patient of mine on Parnate (tranylcypromine) recieved codeine, I now warn all my patients on MAOIs to avoid all narcotic analgesics.'
This is the only report of an interaction between codeine and an MAOI that I've ever seen!
If the procedure is too uncomfortable and you need more sedation, propofol is sometimes used to induce deep sedation - this sedation is normally performed by an anesthetist. Propofol is a powerful IV sleep-inducing drug. As far as I know, there are no reports of propofol interacting with MAOIs. Low blood pressure might occur.
What is your BP at the moment? Do you get dizzy when you stand up?
If you need general anesthesia for your shoulder, if might be useful to give the anesthetist a reliable list of drug interactions, your pdoc could help you produce this. You could stick it on your drug chart!!
Opioid anesthesia (anesthesia based on a very high dose of an opioid such as fentanyl) might not be suitable, one patient taking an MAOI died after receiving opioid anesthesia. The symptoms resembled serotonin syndrome, fentanyl is related to pethidine/meperidine, it is possible that fentanyl may be weakly serotonergic. The death may have occured due to the very high dose given, low doses are probably ok - again, the interaction has not been well studied.
Most general anesthesia involves the administration of lower doses of opioids, the opioid dose can be minimised by giving higher doses of sedative-hypnotics such as propofol or anesthetic gases such as isoflurane. This type of anesthesia may be safer for you. Low blood pressure may be a problem, the anesthetist must be well informed about which blood pressure elevating drugs ('pressors', sympathomimetics) can be safely combined with MAOIs and which need to be avoided.
The following 'pressors' can usually be combined safely with MAOIs if it is important to elevate the patient's blood pressure. Traditional textbooks will often tell you that these drugs must be avoided, it is true that the blood pressure elevation produced by these drugs may be greater in patients taking MAOIs compared with patients not taking MAOIs. Low doses must be given initially, the dose must be carefully titrated/individualised...........
epinephrine/adrenaline
norepinephrine/noradrenaline
methoxamineThe folowing 'pressors' should generally be avoided in patients taking MAOIs, the response may be unpredictable and severe hypertension may result........
ephedrine
metaraminol.......The are many other 'pressors' which also interact serious with MAOIs, I won't list them here because I don't know which ones are used by anesthetists in Thailand. I can send you some more info if you need surgery.
>I JUST got this brilliant idea--that if surgery were necessary, I would enlist the assistance of my psychiatrist (who obviously knows all about MAOIs) and put him in touch with the gastroenterologist (for colonoscopy) or orthopedist (for shoulder). There *are* many doctors who are familiar with MAOIs here; the more important issue, i guess, is whether the anaesthetists are knowledgeable and willing to work with an MAOI patient.
Yes, this is a good idea. You definitely need to get in contact with the people who'll be treating you in advance.
>Are you serious? Opioids might not be effective in my case? So what alternatives could there possibly be, that would also be compatible with Parnate?
A higher dose of Voltaren or another NSAID might be more effective than an opioid. Have you tried taking aspirin 900mg four times a day?
*Do not combine aspirin with diclofenac*
Aspirin and diclofenac are both capable of causing peptic ulcers, if they are combined the risk is dramatically increased.>Truthfully, I'm scared of the gastro-intestinal risks, although I'm in the low-risk category for NSAIDs.
You could ask your doctor about using a gastro-protectant such as lansoprazole.
>>Have you asked your doctor whether it is safe to take a higher dose?
>Yes, but he said that in my case, I'd best cut it out after a max. of 2 months.You never taken a full dose yet so you've got plenty of time :-)
>Never heard of Paracetamol until I came to Thailand.
Where are you from? Paracetamol is called acetaminophen (Tylenol etc) in some countries.
>Would a combo of Diclofenac and aspirin be as effective, do you think? (come to think of it, I've already tried diclofenac w/aspirin at low doses/as needed and saw no improvement)
Combining aspirin with diclofenac is dangerous, it is toxic to the stomach! Taking a higher dose of diclofenac on its own would be safer. Diclofenac can be combined with acetominophen, but not aspirin or other NSAIDs.
>Can't believe it! After all the posts and info I've been reading, to learn this is quite a surprise.
An opioid might be helpful, I'm not saying it wouldn't be. Opioids are not generally first-line for your type of pain though, because other drugs are often more effective. A combination product such as Percocet might be prescribed if paracetamol, diclofenac and muscle relaxants weren't helpful. Percocet is often very constipating, prepare to purchase some laxatives!
>It's made in Japan. Don't know why the distribution is seemingly limited.
Interestingly, a lot of Japanese psych drugs are only marketed in Japan! Many of them are virtually unknown to the West.
Perhaps you could try an increased dose of Myonal if you're still in pain in a few weeks time. I don't know much about Myonal, can't give any info.
RE the shoulder surgery.....
General anesthesia + MAOIs is 'traditionally' contra-indicated. Some anesthetists now believe that such anesthesia can be performed safely in experienced hands; this is what I posted to ace.
Anesthesia + Parnate is unlikely to be as safe as anesthesia w/o Parnate, you will have to weigh up the risks of d/cing the Parnate against the risks of continuing it. I honestly don't know how easy it will be for you to find an anesthetist who is willing to treat you while you're still taking Parnate. Best of luck :-)
Take care,
Ed.PS. An analgesic called nefopam is available in some countries, it *can't* be combined with Parnate though!!
Posted by Larry Hoover on March 19, 2005, at 17:17:42
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover, posted by cubbybear on March 19, 2005, at 6:12:15
> Hi Larry,
> Well, you sure gave me the scoop on the injury, and I suspect that what i've got is probably a Garden of Eden in comparison. I can only wish you the best in overcoming this horrendous ordeal.Thanks. And I sure didn't mean to make you think in terms of comparisons. Pain is pain.
> In your case I suppose that the oxycodone and "heavy-duty" meds are all that are viable for the pain, but I was wondering if you' ve ever tried Neurontin and if so, can you assess if it's helpful in any way.
No, I haven't yet been able to get it prescribed. I plan to ask for it when I see my doctor next week. I don't like taking Toradol.
Regards,
Lar
Posted by Larry Hoover on March 19, 2005, at 17:21:59
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover, posted by ed_uk on March 18, 2005, at 7:29:22
Since you have access to some superb databases....
One of the things that most annoys me about my current situation is how it disturbs my sleep. If I undermedicate, the pain wakes me. But even if I think I get the dose of meds right (little or no pyschoactive effect), I have a hell of a time getting to sleep, and staying there. I already had a sleep problem, for which I've used temazepam and trimipramine for an extended period of time, but even with those meds, the oxycodone and/or the keterolac seems to make my brain active, and induce vivid dreams. Is that consistent with your literature, as adverse effects? I can't find much on that subject. I seem to be between a rock and a hard place, on the sleep thing, and I'm becoming exceedingly worn down as a result, due to chronic sleep deprivation.
Thanks in advance,
Lar
Posted by ed_uk on March 19, 2005, at 18:20:17
In reply to Re: Hey Ed... » ed_uk, posted by Larry Hoover on March 19, 2005, at 17:21:59
Hi Lar!
>Since you have access to some superb databases....
I'm not at University for the next three weeks, I don't have access from home :-(
>But even if I think I get the dose of meds right (little or no pyschoactive effect), I have a hell of a time getting to sleep, and staying there.
I've certainly heard of opioids causing insomnia. Morphine is sometimes claimed to be more sedating than oxycodone, perhaps you could use it as an alternative to oxy in the evening and at night. Oral morphine is less potent than oral oxycodone, the conversion factor is about 1.5 (variable: 1-2). Opioids do sometimes induce vivid dreams, tolerance to this effects doesn't generally seem to occur.
Quite a few CNS reactions have apparantly been reported with ketorolac, including anorexia nervosa! Indomethacin is another NSAID which is known for its CNS side effects.
Just out of interest, have you ever tried flurbiprofen? I once read that it was a more effective analgesic than other NSAIDs, I don't know why this would be though- perhaps it was a load of rubbish!
>I've used temazepam and trimipramine for an extended period of time.
Do they still work as well as they used to? Have you tried zopiclone? It's claimed to be associated with less tolerance than temazepam.
Best regards,
Ed.
Posted by Phillipa on March 19, 2005, at 20:23:16
In reply to Re: Hey Lar... » Larry Hoover, posted by ed_uk on March 19, 2005, at 18:20:17
Hi Ed! I just Babbled you. Are you home for 3 weeks? Does that mean I should continue to Babble you? Thanks Phillipa O
Posted by cubbybear on March 20, 2005, at 4:59:43
In reply to Re: Sedation and general anesthesia » cubbybear, posted by ed_uk on March 19, 2005, at 14:24:13
>> Standard practice in the UK is to give an IV sedative, usually midazolam (Hypnovel, Versed) and an opioid, often pethidine (meperidine, Demerol). You must *not* let them give you any pethidine/meperidine!!!
Not to worry; I've long known about the dangers of meperidine.
>
>>
> What is your BP at the moment? Do you get dizzy when you stand up?It's fine 95% of the time--stays at around 120/80.
I get a little dizziness only when I stand up after crouching low on the floor (of the bookshop) for a few minutes. I think it's called orthostatic hypotension and it goes away in less than a minute.>
>> >Are you serious? Opioids might not be effective in my case? So what alternatives could there possibly be, that would also be compatible with Parnate?
>
> A higher dose of Voltaren or another NSAID might be more effective than an opioid. Have you tried taking aspirin 900mg four times a day?No--that sounds wildly excessive and a bit risky, even if it is aspirin.
> *Do not combine aspirin with diclofenac*
> Aspirin and diclofenac are both capable of causing peptic ulcers, if they are combined the risk is dramatically increased.I'm very glad you told me. I think I tried it on one occasion to see if it offered pain relief. But it didn't anyway.
>
.
>
> Where are you from? Paracetamol is called acetaminophen (Tylenol etc) in some countries.OH, now I get it! I'm from the U.S., and there, the big name is Tylenol, with generic name acetaminophen. And, all this time, I thought that Paracetamol is something completely different. Live and learn.
>
> > Combining aspirin with diclofenac is dangerous, it is toxic to the stomach! Taking a higher dose of diclofenac on its own would be safer. Diclofenac can be combined with acetominophen, but not aspirin or other NSAIDs.Very glad you told me.
>
> >>A combination product such as Percocet might be prescribed if paracetamol, diclofenac and muscle relaxants weren't helpful. Percocet is often very constipating, prepare to purchase some laxatives!This could be a welcome side effect, since I ordinarily have a mild case of irritable bowel syndrome (IBS) which is manifest in occasional, unpredictable, nuisance diarrhea.
>
> >>
>>
> RE the shoulder surgery.....
>
> General anesthesia + MAOIs is 'traditionally' contra-indicated. Some anesthetists now believe that such anesthesia can be performed safely in experienced hands; this is what I posted to ace.
>
> Anesthesia + Parnate is unlikely to be as safe as anesthesia w/o Parnate, you will have to weigh up the risks of d/cing the Parnate against the risks of continuing it. I honestly don't know how easy it will be for you to find an anesthetist who is willing to treat you while you're still taking Parnate. Best of luck :-)Well, shoulder surgery might not even be called for in the long run. I'll just have to pray that this will heal/become tolerable in time.
Thanks for all your great advice. By the way, are you in the medical profession? You seem to know more than a few dozen doctors combined.
cubbybear
>
>
Posted by cubbybear on March 20, 2005, at 5:12:02
In reply to Re: Percodan/Percoset Experiences?? » Larry Hoover » cubbybear, posted by Larry Hoover on March 19, 2005, at 17:17:42
>> > In your case I suppose that the oxycodone and "heavy-duty" meds are all that are viable for the pain, but I was wondering if you' ve ever tried Neurontin and if so, can you assess if it's helpful in any way.
>
> No, I haven't yet been able to get it prescribed. I plan to ask for it when I see my doctor next week. I don't like taking Toradol.Has there been a problem with getting UK doctors to prescribe it? Can't imagine that. . .it seems pretty amazing to me that, here is a drug that is quite viable for certain kinds of severe pain (neuropathic) and it poses a much better/safer risk of habituation/addiction than opioids. I can attest to its efficacy, by how it knocked out my horrific (neuropathic) pain from herpes zoster. I also take advantage of Neurontin's side-effect of somnolence to help me sleep, by alternating it with Xanax, in order to avoid getting dependent again on a benzo for insomnia.
I don't know about the situation with Neurontin in the US, but here in Thailand, where the govt. has cracked down on availability/dispensing of codeine, Neurontin can actually be purchased OTC!! (but then again, you'd be shocked at the number of meds that can be purchased OTC here anyway, that require an Rx in the U.S.). The only drawback I see with Neurontin at present is that the price is a bit steep; the generic gabapentin is not available.>
Posted by ed_uk on March 20, 2005, at 10:05:49
In reply to Re: Sedation and general anesthesia » ed_uk, posted by cubbybear on March 20, 2005, at 4:59:43
Hi Cubbybear!
>No--that sounds wildly excessive and a bit risky, even if it is aspirin.
900mg four times a day is a relatively 'standard' dose of aspirin for pain. 600mg four times a day may provide some small relief. Single doses <600mg are unlikely to provide any relief. 75-300mg/day is used for cardiovascular prophylaxis, these doses provide no pain relief or anti-inflammatory effect. The maximum 24 hour dose of aspirin for rheumatic disease is 8000mg in six divided doses, such high doses are used only under close supervision/monitoring. 600-900mg four times a day is a normal dose for pain.
>By the way, are you in the medical profession?
No, I'm a student.
Regards,
Ed.>And, all this time, I thought that Paracetamol is something completely different.
Lol, people do!
Posted by ed_uk on March 20, 2005, at 10:08:12
In reply to Re: Neurontin » Larry Hoover, posted by cubbybear on March 20, 2005, at 5:12:02
Hi!
>you'd be shocked at the number of meds that can be purchased OTC here
What can you buy OTC that needs a prescription in the US?
Ed.
Posted by ed_uk on March 20, 2005, at 18:06:25
In reply to Re: Sedation and general anesthesia » ed_uk, posted by cubbybear on March 20, 2005, at 4:59:43
Hi Cubbybear!
Just a little PS........
>Not to worry; I've long known about the dangers of meperidine.
I knew you would have, I just thought I'd mention it since it's often used during colonoscopy. Is the drug called pethidine or meperidine in Thailand? Do you know the brand name?
Ed.
Posted by cubbybear on March 21, 2005, at 0:40:26
In reply to Re: Neurontin » cubbybear, posted by ed_uk on March 20, 2005, at 10:08:12
> Hi!
>
> >you'd be shocked at the number of meds that can be purchased OTC here
>
> What can you buy OTC that needs a prescription in the US?
>
> Ed.All pharmacies, down to the smallest, offer dozens of competing brands of topical skin medications, cortisone-based and non-cortisone based for dermatoses of all kinds, including fungal infections. No Rx needed. The package insert is always available for the asking. It's printed in English and Thai.
Most pharmacies have all the major antibiotics, such as amoxycillin, tetracycline, and cipro.
Shockingly, some pharmacies offer anti-depressants Prozac and Zoloft without a prescription, perhaps others as well. This blows my mind altogether and points up the absurdity of government regulation. Misuse of these meds can cause serious, if not life-threatening situations, and yet one can no longer walk into the drugstore and obtain a benzo type drug or opioid. They're available only at hospital pharmacies. MAOI antidepressants Parnate, Nardil and Marplan are prohibited even in hospitals, hence my need to travel to the U.S. to get a year's supply.
Regardless, living here brings its supreme advantages, as when one needs to purchase an anti-fungicidal cream every so often, and can stroll into the pharmacy and purchase a tube of the appropriate stuff without having to phone the doctor. And the prices are a fraction of what they are in the U.S. (I recall that, even at the hospital pharmacy, Zoloft cost exactly one half of what the on-line pharmacies were charging.) Come on over some time, I'll give you the tour of your life.
Posted by cubbybear on March 21, 2005, at 1:18:11
In reply to Re: Pethidine » cubbybear, posted by ed_uk on March 20, 2005, at 18:06:25
>> >Not to worry; I've long known about the dangers of meperidine.
>
> I knew you would have, I just thought I'd mention it since it's often used during colonoscopy. Is the drug called pethidine or meperidine in Thailand? Do you know the brand name?
>
Sorry I don't but you can be sure I'd find out about it and tell them, if need be.
Posted by ed_uk on March 21, 2005, at 9:56:21
In reply to Re: Pethidine » ed_uk, posted by cubbybear on March 21, 2005, at 1:18:11
Hi Cubbybear!
>All pharmacies, down to the smallest, offer dozens of competing brands of topical skin medications, cortisone-based and non-cortisone based for dermatoses of all kinds, including fungal infections.
Here, you can buy hydrocortisone OTC. A few antifungal creams are available: miconazole, ketoconazole, terbinafine (Lamisil) etc. Can't you buy antifungal creams in the US?
>Most pharmacies have all the major antibiotics, such as amoxycillin, tetracycline, and cipro.
Sounds like Spain and Greece! No antibiotics here!
>MAOI antidepressants Parnate, Nardil and Marplan are prohibited even in hospitals, hence my need to travel to the U.S. to get a year's supply.
:-( They seem to be prohibited in a lot of countries, it's sad.
>Come on over some time, I'll give you the tour of your life.
LOL, that would be fantastic!
>Sorry I don't but you can be sure I'd find out about it (pethidine, meperidine, Demerol etc) and tell them, if need be.
I was just worried that they'd give you something and you wouldn't realise that it was meperidine.
Best regards,
Ed.PS. Cubbybear is a cute name!
Posted by cubbybear on March 21, 2005, at 10:39:55
In reply to Re: Thailand » cubbybear, posted by ed_uk on March 21, 2005, at 9:56:21
> Here, you can buy hydrocortisone OTC. A few antifungal creams are available: miconazole, ketoconazole, terbinafine (Lamisil) etc. Can't you buy antifungal creams in the US?
Having been in the Land of Smiles for about 6 years now, I've been out of Western circulation and maybe the laws in the U.S. have changed since '99. But the last time I had a dermatological problem in the U.S. (late 90s) you needed an Rx to get cortisone creams above a certain percentage concentration. I didn't need a fungal cream until I got to Thailand, so maybe I was wrong about needing an Rx for it in the U.S. But I'm sure about the strong cortisones.
>
>
> PS. Cubbybear is a cute name!]Thanx--Forner friends in the U.S. who didn't even know each other coincidentally called me by the same nickname. So it must be something in my appearance. I guess the name fits since I sometimes stick my nose where it shouldn't go and get stung or stuck.
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