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notloki

Chronic pain med regimen issue

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So Celebrex (Celecoxib), an NSAID, is part of my cocktail for pain. I can take it PRN or all the time. At first I did PRN as Celebrex can irritate the GI lining, sometimes to the point of causing a bleed. I also have significant GERD (reflux) that is well controlled by famotidine. I did OK on PRN dosing the Celebrex but it works a lot better if taken all the time. I decided to try twice a day dosing and I made it 5-6 days and then was awoken by major burning in my chest and esophagus from reflex. I never have breakthrough reflux so it is the Celebrex causing GI upset. I downed 3 tums, 8 mg Zofran, and 40 mg famotidine and was much better quickly.

The issue is that after 3 days of daily dosing I felt really great. All the little aches and pains went away. I did not have breakthrough pain requiring hydrocodone to control. I need to talk to my pain doc, there may be an alternate day dosing or maybe I can get away with once a day. One confounding problem is I use Voltaren Gel 1% to control most of the neck pain. It is a powerful NSAID and is absorbed through the skin. It does get to the GI and can do the same damage Celebrex can but I have been on it as needed with no reflux/GI problems.

I also receive injections into my spine at C-2,C-3,C-4 of methylprednisone and marcaine, a long acting local anesthetic. The works well in stopping pain for about a month then fades. The methylprednisone wrecks havoc with my sugar level and therefor diabetes. So I am trying to move away from getting the injections. I was hoping Celebrex would be the answer and I could drop or curtail getting the injections.

If anyone has some insight or idea(s) I would appreciate it.  I would be fine with taking hydrocodone all the time but the establishment does not like this.

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My knowledge in this area is limited, but according to medscape once daily dosing is acceptable for some types of pain, so that might be a place to start 

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Yep, the PI does not move to twice a day dosing until Rheumatoid Arthritis, mine is more on the osteoarthritis level. With the famotidine I think I could handle once a day in the morning. Avoid lying down  Thanks.

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Celecoxib's half-life is 11.2 hours, but is highly variable due to prolonged absorption. It's primarily a CYP2C9 substrate/inhibitor + CYP3A4 substrate.

I'm assuming you take 200 mg qd prn, and your daily dosing has been 200 mg qd? This can be divided up as 100 mg bid.

I would highly suggest a proton-pump inhibitor in lieu of a H2 histamine antagonist like famotidine. Even just omeprazole (Prilosec) starting at 20 mg and going up as needed can help far better. It will take a little while to start working though, so maybe not ditch your famotidine immediately. This would definitely be something to discuss with any of your docs, probably your pain doc. Esomeprazole (Nexium) I believe not only has protective effects against acid reflux but an reverse long-term damage done by acid erosion to the esophagus (if this med had been around when my granddad he started to have his esophageal cancer in the mid 1990s, it could have possibly saved his life... but the racemic omeprazole was just then coming around...). They market NSAIDs + PPIs in weighted doses now, I believe. I believe though that there is one NSAID + H2 antagnoist made like this, too, and I believe it is famotidine.

Possibly something else to consider is the selectively peripheral anticholinergic glycopyrrolate (Robinul, Robinul Forte). It acts selectively and preferentially in the peripheral as opposed to the central nervous system (I take it for hyperhidrosis with zero side effects), and as such it could be a good adjunct to reduce acid production, perhaps? And since it doesn't work in the CNS, no concerns of cognitive effects, vision disturbance, etc. 

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I started taking 200 mg twice a day, prn. No problems. I moved to continuous dosing to get better symptom control. I got that at the expense of reflux. So far once a day dosing in the AM is working.

I am taking 40 mg famotidine twice a day. I tried several PPI's but found the H blockers controlled my symptoms better. The allergist likes the fact I have all my histamine receptors are blocked and feels it is contributing to controlling my allergies, my generalist concurs. During trials of some PPI's maximum doses controlled my reflux not as well as a H blocker.

The one PPI I did not try was Nexium and I see the 24 hr version is OTC. I am going to continue on with my present dosing and see it does not increase reflux. I bought some Nexium at the store and will add that if the reflux comes back. Thanks you for your advice. Nexium is a good idea.

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On 6/18/2020 at 10:04 AM, notloki said:

I started taking 200 mg twice a day, prn. No problems. I moved to continuous dosing to get better symptom control. I got that at the expense of reflux. So far once a day dosing in the AM is working.

I am taking 40 mg famotidine twice a day. I tried several PPI's but found the H blockers controlled my symptoms better. The allergist likes the fact I have all my histamine receptors are blocked and feels it is contributing to controlling my allergies, my generalist concurs. During trials of some PPI's maximum doses controlled my reflux not as well as a H blocker.

The one PPI I did not try was Nexium and I see the 24 hr version is OTC. I am going to continue on with my present dosing and see it does not increase reflux. I bought some Nexium at the store and will add that if the reflux comes back. Thanks you for your advice. Nexium is a good idea.

Combining PPI + H2 blocker is a good strategy IMO, especially with Nexium. You can get generic prescribed for cheaper if you decide you like it, but a lot of insurance companies, especially Medicare, have become really pissy about prescribing drugs that are enantiomers of other drugs, like omeprazole/esomeprazole, for example. Even citalopram/escitalopram they're getting pissy about...

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Not sure if this would be doable, but instead of oral NSAIDs and trying to tweak reflux meds, have you considered Cymbalta? It's FDA approved for osteoarthritis, low back pain, fibromyalgia, depression, etc. (tho it may necessitate switching from buproprion). I was on it for about 6 months for BP 2 depression and pain; it made the depression worse : ( , but I was actually shocked at the degree to which it mitigated my spinal pain (I've had 3 spinal surgeries, lost most of C5-6 but gained a titanium cage, plus 2 fusions- ugh!). I'm really bummed I can't take it anymore, but if it can make such a difference in my train wreck, it might be worth asking about?

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Bupropion and duloxetine (Cymbalta) can in most cases be taken together safely. That's a good idea if @notloki can tolerate serotonergic meds.

Also, there are the TCAs, which are even better for pain, but that would definitely necessitate a switch from bupropion, and some of them, like amitriptyline, protriptyline, and nortriptyline, are pretty anticholinergic, and that's a big concern of his. Desipramine is largely devoid of anticholinergic effects, but it isn't said to be that effective for pain.

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16 hours ago, mikl_pls said:

Also, there are the TCAs

It's been so long I'd almost forgotten- yes, I can personally verify that nortriptyline and amitriptyline can also be effective for pain, but I found both VERY anticholinergic. I also found that the effectiveness completely faded after about a year, unfortunately.

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