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Nelly Ziade-Zoghbi, MD, MPH Rheumatology department, Hotel-Dieu de France

IV therapy for radicular pain A literature review and retrospective analysis of a case series at HDF. Nelly Ziade-Zoghbi, MD, MPH Rheumatology department, Hotel-Dieu de France. Agenda. 1- Literature review of IV treatments in radiculopathies

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Nelly Ziade-Zoghbi, MD, MPH Rheumatology department, Hotel-Dieu de France

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  1. IV therapy for radicular painA literature review and retrospective analysis of a case series at HDF Nelly Ziade-Zoghbi, MD, MPH Rheumatology department, Hotel-Dieu de France

  2. Agenda 1- Literature review of IV treatments in radiculopathies 2- Case series at HDF: IV pentoxifylline in radiculopathies

  3. Agenda 1- Literature review of IV treatments in radiculopathies 2- Case series at HDF: IV pentoxifylline in radiculopathies

  4. www.pubmed.com

  5. NSAIDs • Ketoprofene 100 mg / 8hrs for 3 days •  transcient effect Etienne JC. Gaz Med 1986

  6. Corticosteroids • RCT, sciatica < 6 weeks • 65 patients • High-dose pulse methylprednisolone (500mg) •  Transcient effect / small magnitude • No effect on functional disability Finckh et al, Spine 2006

  7. Anti-TNF alpha • Role of anti-TNF alpha in the pathogenesis of the disco-radicular conflict • [Rannou F, Revel M. L’actualite rhumatologique 2005] • [Mulleman et al. Joint Bone Spine 2006] • One RCT: 40 pts suffering from LS (2-12 wks)  one infliximab infusion  1-year follow-up • Improvement 67% versus 63% (p 0.72) • Benefit+with Modic changes at symptomatic level • 20%  surgery • [Korhonen, Spine 2005]

  8. What about Pentoxifyllin? • PTX is a PDE4 inhibitor increasing intracellular cAMP and stimulating PKA activity. • Primary actions: PTX increases red blood cell deformability, reduces blood viscosity and decreases the potential for platelet aggregation and thrombus formation • It is also a known inhibitor of TNF-alpha Marques et al. Am J Respir Critic Care Med 1999

  9. Evidence from PTX • Effects in experimental nerve injury • Intraperitoneal PTX in rats with crushed sciatic nerve • Electrophysiologic studies 3 weeks later: better amplitudes of compound muscle action potentials • Suggests positive effect on axon regeneration Baykal el al. Turk J Med Sci 2002.

  10. Evidence from PTX • Effects on nerve conduction velocity and blood flow in diabetic rats • 2 weeks PTX • Diabetic deficits in sciatic motor and saphenous sensory nerve conduction velocity were 56.5% and 69.8% corrected, respectively • Sciatic endoneurial blood flow was 50.4% corrected Flint et al. Int J Experimental Diab Res 2000

  11. Agenda 1- Literature review of IV treatments in radiculopathies 2- Case series at HDF: IV pentoxifylline in radiculopathies

  12. Previous Treatments NSAIDs: 65% Epidural Injections: 45% 7% 29% 18% Analgesics: 65% 18%

  13. Protocols

  14. Δ VAS (%) 38 months [3-84]

  15. VAS response categories over time

  16. Outcomes

  17. Adverse events

  18. Who benefits more? *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  19. Differences in Protocols *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  20. Role of associated NSAIDs

  21. Summary of main results • Δ VAS radicular pain around 50% (immediate and late response) • Good responders tend to be younger, male and non-smokers • Response at least partially explained by associated / previous NSAIDs

  22. Study limitations • Retrospective analysis (recall bias) • Small number of patients • Different treatment protocols • Different treatments associations (open study) • No placebo arm / No blinded treatment

  23. Study strenghts • Very few lost to follow-up (10.7%) • Evaluation of initial hospital chart + telephone contact with patients • Careful identification of all associated treatments • Careful identification of tolerability profile

  24. Conclusion • Need in practice for a safe and efficacious treatment in resistant radiculopathies • Pentoxifylline / Anti-TNF family needs further dedicated well-designed studies, that takes into account associated treatments, especially NSAIDs

  25. Thank you for your attention

  26. Back-up

  27. Immediate response *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  28. Immediate response *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  29. One month response *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  30. One month response *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  31. Who benefits more? *Good responders = Δ VAS above median (higher range of response) **Non-responders = Δ VAS below median

  32. Differences in protocols

  33. Mean Δ VAS radicular pain: No increase in response with PTX dose

  34. Median ΔVAS response over time

  35. Responders categories MEDIAN 70% 90% 50%

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