Botox for neuropathic pain

[drg123]

Has anyone here successfully used Botox (subcutaneous) for neuropathic pain (e.g. diabetic neuropathy).
The Europeans have been using for some time and there are numerous good studies

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2816%2900017-X/fulltext

I don't think Botox is approved here for this indication but one could do off-label, cash pay?
Thoughts?

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[DODOCSS]

Yes. Post thoracotomy pain.

 

[drg123]

Yes. Post thoracotomy pain.

How did you handle the finances? Cash pay or did you get it covered by insurance somehow? Or did you call it a 'trigger point injection'?

 

[clubdeac]

Yes for PHN…was at the VA

 

[MitchLevi]

Botox in a scar or a neuroma is helpful. Neuroma injxns with Botox are painful.

 

[GlowInTheDark]

Yes. Post thoracotomy pain.

Done as an ICNB?

 

[DODOCSS]

Done as an ICNB?

surrounding the scar

 

[clubdeac]

Done as an ICNB?

No it actually involved VI-II. Just injected the the face in those two distributions in the face. There are several papers out there describing the technique

 

[Orin]

I've done it in CRPS as they'll sometimes have a focal dystonia, and then use the rest in a grid pattern after a nerve block proximal. If you're doing it for pure neuropathic pain, it would be cash pay or done for VA/etc.

Key thing here is to just do SQ injections as you're not trying to get into the muscle at all.

 

[SeniorWrangler]

Has anybody used Xeomin for this? Cheaper and it’s off label either way.

 

[joshmir]

Not sure if this is helpful, but years ago, I spoke with the medical science liaison for xeomin

He was a pharmacist at the VA

He said that they had done an internal data review at the VA and found that for what they had used xeomin for, the efficacy was non-inferior to Botox, at a conversion rate of 1:1 unit

If that guy is still the medical science liaison, he may be able to query their database for that

But then, again, he would still be the medical science liason and perhaps be biased in favor of xeomin

 

[drg123]

Anyone ever have success doing off label with a letter of medical necessity to payor? the local rep suggested I might try this, citing studies and such. I feel like this is something the companies should be interested in getting on-label indication for. Huge number of patients would be candidates and it's safe and fast.

 

[Birdstrike]

N of 1

Diabetic peripheral neuropathy
Patient did some research and asked for it.
Cash pay
Patient got no relief

 

[drg123]

N of 1

Diabetic peripheral neuropathy
Patient did some research and asked for it.
Cash pay
Patient got no relief

Thanks for the intel. Sorry to hear it didn't pan out. I think NNT is still something like 3. So checks out.

 

[lobelsteve]

Thanks for the intel. Sorry to hear it didn't pan out. I think NNT is still something like 3. So checks out.

Umm, WTH?

Number Needed to Treat (NNT) — Centre for Evidence-Based Medicine (CEBM), University of Oxford

The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.).

www.cebm.ox.ac.uk

 

[drg123]

Umm, WTH?

View attachment 386949

Number Needed to Treat (NNT) — Centre for Evidence-Based Medicine (CEBM), University of Oxford

The Number Needed to Treat (NNT) is the number of patients you need to treat to prevent one additional bad outcome (death, stroke, etc.).

www.cebm.ox.ac.uk

I am using it in this context, not the one you cite above. It can be used both for benefits and harms

Gabapentin for Chronic Neuropathic Pain – TheNNT

thennt.com

Number needed to treat (NNT) – Primary Care Notebook

An article from the public health section of Primary Care Notebook: Number needed to treat (NNT).

primarycarenotebook.com

And I stand corrected. Here is the source. I said 3. It's apparently 1.9.

1.Finnerup, N. B. et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurology 14, 162–173 (2015).

 

[lobelsteve]

Botulinum toxin type A​

Six RCTs evaluated the efficacy of a single administration of BTX-A (50–200 units subcutaneously in the painful area) in peripheral neuropathic pain. The smaller studies had a positive primary outcome (NNT of 1·9 (1·5–2·4) for four studies) with a very low placebo effect, but one large unpublished study was negative. Safety was generally excellent.


The NNT you quoted is not including the large trial that was negative.

 

[lobelsteve]

A better study/review:

Botulinum Toxin for the Treatment of Neuropathic Pain

Botulinum toxin (BoNT) has been used as a treatment for excessive muscle stiffness, spasticity, and dystonia. BoNT for approximately 40 years, and has recently been used to treat various types of neuropathic pain. The mechanism by which BoNT acts on neuropathic ...

www.ncbi.nlm.nih.gov

 

[au bon pain]

I am using it in this context, not the one you cite above. It can be used both for benefits and harms

Gabapentin for Chronic Neuropathic Pain – TheNNT

thennt.com

Number needed to treat (NNT) – Primary Care Notebook

An article from the public health section of Primary Care Notebook: Number needed to treat (NNT).

primarycarenotebook.com

And I stand corrected. Here is the source. I said 3. It's apparently 1.9. View attachment 386950


1.Finnerup, N. B. et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurology 14, 162–173 (2015).

Not a knock on you, but when the authors report an NNT of 4.3 for “Strong Opioids”…the underlying methodology of this paper immediately takes a hit

 

[SpineandWine]

How did you handle the finances? Cash pay or did you get it covered by insurance somehow? Or did you call it a 'trigger point injection'?

Piggy backing on that

Any knowledge of what wRVU is for Botox for spasticity in hospital

 

[Ducttape]

it should be noted in your meta-analysis that there were 6 botox studies, total 137 patients, significantly lower than any of the other treatments, and this was the only interventional treatment.

like lobel stated:

Botulinum toxin type A​

Six RCTs evaluated the efficacy of a single administration of BTX-A (50–200 units subcutaneously in the painful area) in peripheral neuropathic pain. The smaller studies had a positive primary outcome (NNT of 1·9 (1·5–2·4) for four studies) with a very low placebo effect, but one large unpublished study was negative. Safety was generally excellent.

that NNT is only for the smaller studies, did not include the large unpublished one.

the strength of recommendation was weak for use of botox and were recommended as a 3rd line agent in peripheral neuropathy only.

and in their lengthy summary, botox is not mentioned at all.

 

[lobelsteve]

it should be noted in your meta-analysis that there were 6 botox studies, total 137 patients, significantly lower than any of the other treatments, and this was the only interventional treatment.

like lobel stated:

that NNT is only for the smaller studies, did not include the large unpublished one.

the strength of recommendation was weak for use of botox and were recommended as a 3rd line agent in peripheral neuropathy only.

and in their lengthy summary, botox is not mentioned at all.

If they included the larger unpublished study (suppressed by Allergan?), what do you think the analysis would show?

 

[drg123]

That Lancet review was from 2015. The strongest study to date came out after

https://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2816%2900017-X/fulltext

Here is a recent review with updated studies

https://www.sciencedirect.com/science/article/pii/S0041010123001940

Not saying it's a silver bullet, but in the right patients, it's something low risk and potentially beneficial. Not sure about the unpublished studies. Can't appraise their methods if unpublished.

 

[Ducttape]

seems appropriate to try after they have failed the first and second line treatments.


these patients did fail first and second line treatments, right?


and btw, the lancet article as you correctly posted was a review. id be less likely to use that as basis for decision making than RCTs and other studies.

the first article was based on a total of 66 total patients. not a huge sample size. efficacy was primarily with 2 injections. studied to 24 weeks.

6.5 mean pain intensity at baseline down to 4.6 for botox, compared to 6.4 to 5.8 for placebo.

 

[mohandess]

On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks

 

[Dansk2011]

On a side note, has anyone had success using Botox for TPIs like in traps? A neurologist down my street does it and has a lot of success. His patients love it and don’t come back too often. Thanks

I have patients that I inherited from a previous provider who receive botox for neck pain diagnosed as "cervical dystonia". I felt a little uncomfortable continuing with the procedures as, at least in my opinion, they don't have true dystonia, but the patients swear by them and have done really well so I just continued them. Not a lot but enough to believe that it can be effective.