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Reflex Sympathetic Dystrophy (RSD) (CRPS) Message Board


Reflex Sympathetic Dystrophy (RSD) (CRPS) Board Index


Re: What's Next??
Aug 14, 2004
Hi Kate, those were two good answers. I'm really glad Julie & Sharon are around to help people out with their first person perspectives.

You might be interested in doing a google.com search for " rsdfoundation.usf.edu/en/en_clinical_practice_guidelines.html " , copy & paste text within quotes for a "Clinical Practice Guidelines - Third Edition" although not everyone would agree with it.

There is some palliative data on SCS trials & intraspinal pumps of morphine with adjuvants bupivicaine or sometimes baclofen or clonidine (which is radically different than the drug levels when taken systemically).

-Julie, may I ask how often do you get blocks, total # to date, & avg pain level & other treatment?

-Sharon, may I ask what has been your experience with the placement - maintenance of the implanted pump & could you describe any side effects & avg pain level & its acceptance by yourself & others in your life (is this your sole medical tx)?

The prolonged subanesthetic IV ketamine article I referenced is a newer rather unique alternative with less published data to date however. My main concern with any ketamine approach that I continue to investigate (as I'm considering it) is are there long term cognitive adverse effects. There is rodent data that NMDA antagonists like ketamine are neurotoxic when administered alone depending on dose, duration, age, sex but no comparable human data. To mitigate adverse effects adjuvant safeners have been employed. With the low dose subanesthetic approach (where it alone has also been used), I haven't heard vocal complaints yet in the limited # who have tried it. Some reports of 50% response rates lasting months to years with this less invasive approach. Maintenance strategies are being developed.

With the invasive prolonged high dose ICU anesthetic ketamine approach (only midazolam coadministration alone reported-there may be better safeners used now) there have been suprisingly only reports of "slight psychomimetic effects up to 3 months" in 3/10 treated in that preliminary series although I would like to hear patient perpectives. All of these patients had intractable CRPS & 5/10 had generalized full body RSD. All 10/10 were reported to respond with immediate absence of CRPS-1 signs after intervention with about 50% months to years-to date without relapse. Maintenance strategies are also being developed including less invasive ones.

Ketamine is unique in that as a potent NMDA antagonist there is a lot of basic science & growing anecdotal reports that it may have the ability to resolve the principal mechanism of some primary neuropathic pain states like RSD. I think for this reason it deserves special attention. Some doctors also combine several of these treatment approaches if necessary.

References:

Woolf CJ, Thompson SW. The induction and maintenance of central sensitization is dependent on N-methyl-D-aspartic acid receptor activation; implications for the treatment of post-injury pain hypersensitivity states. Pain. 1991 Mar;44(3):293-9. PMID: 1828878 [PubMed - indexed for MEDLINE]

Eisenberg E, Pud D. Can patients with chronic neuropathic pain be cured by acute administration of the NMDA receptor antagonist amantadine intravenously? Pain. 1998 Feb;74(2-3):337-9. - PMID: 9520249 [PubMed - indexed for MEDLINE]

Newcomer JW, Farber NB, Jevtovic-Todorovic V, Selke G, Melson AK, Hershey T, Craft S, Olney JW. Ketamine-induced NMDA receptor hypofunction as a model of memory impairment and psychosis. Neuropsychopharmacology. 1999 Feb;20(2):106-18. - PMID: 9885791 [PubMed - indexed for MEDLINE]

Sang CN. NMDA-receptor antagonists in neuropathic pain: experimental methods to clinical trials. J Pain Symptom Manage. 2000 Jan;19(1 Suppl):S21-5. Review. - PMID: 10687335 [PubMed - indexed for MEDLINE]

Tomitaka M, Tomitaka S, Rajdev S, Sharp FR. Fluoxetine prevents PCP- and MK801-induced HSP70 expression in injured limbic cortical neurons of rats. Biol Psychiatry. 2000 May 1;47(9):836-41. - PMID: 10812043 [PubMed - indexed for MEDLINE]

Farber NB, Jiang XP, Heinkel C, Nemmers B. Antiepileptic drugs and agents that inhibit voltage-gated sodium channels prevent NMDA antagonist neurotoxicity. Mol Psychiatry. 2002;7(7):726-33. - PMID: 12192617 [PubMed - indexed for MEDLINE]

Farber NB, Kim SH, Dikranian K, Jiang XP, Heinkel C. Receptor mechanisms and circuitry underlying NMDA antagonist neurotoxicity. Mol Psychiatry. 2002;7(1):32-43. - PMID: 11803444 [PubMed - indexed for MEDLINE]

Low SJ, Roland CL. Review of NMDA antagonist-induced neurotoxicity and implications for clinical development. Int J Clin Pharmacol Ther. 2004 Jan;42(1):1-14. Review. - PMID: 14756381 [PubMed - indexed for MEDLINE]

- Relevant references I mentioned in a separate thread:

Md RE, Correll GE. Successful treatment of a nine year case of complex regional pain syndrome type-I (reflex sympathetic dystrophy) with intravenous ketamine-infusion therapy Pain Med. 2002 Jun;3(2):147-55. - PMID: 15102163 [PubMed - in process]

Maleki J. "Sensitization": is there a cure? Pain Med. 2002 Dec;3(4):294-7. - PMID: 15099233 [PubMed - in process]

Kiefer RT, Rohr P, Ploppa A, Dieterich H, Schwartzman RJ et al. Ketamine-Midazolam Anesthesia for intractable Complex Regional Pain Syndrome-Type 1 (CRPS-1). IASP 2002 Conference

Ploppa A, Kiefer RT, Schwartzman RJ et al. - Skin Blood Flow Changes During Ketamine-Midazolam Anesthesia for Intractable CRPS1. IASP 2002 Conference

Olney JW, Farber NB. NMDA antagonists as neurotherapeutic drugs, psychotogens, neurotoxins, and research tools. Neuropsychopharmacology. 1995 Dec;13(4):335-45. - PMID: 8747758 [PubMed - indexed for MEDLINE]

Handa F, Tanaka M, Nishikawa T, Toyooka H. Effects of oral clonidine premedication on side effects of intravenous ketamine anesthesia: a randomized, double blind, placebo-controlled study. J Clin Anesth. 2000 Feb;12(1):19-24. - PMID: 10773503 [PubMed - indexed for MEDLINE]

Jevtovic-Todorovic V, Wozniak DF, Powell S, Nardi A, Olney JW. Clonidine potentiates the neuropathic pain relieving action of MK-801 while preventing its neurotoxic and hyperactivity side effects. Brain Res. 1998 Jan 19;781(1-2):202-11. - PMID: 9507131 [PubMed - indexed for MEDLINE]

Olney JW et al. NMDA antagonist neurotoxicity: mechanism and prevention. Science. 1991 Dec 6;254(5037):1515-8. - PMID: 1835799 [PubMed - indexed for MEDLINE]





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