Endocrinology case No2.Diabetic Neuropathy.

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Endocrinology case No2.Diabetic Neuropathy.

হিমেল সাহেব ৪৭ বছর বয়স, ৫ বছর থেকে ডায়াবেটিস, HBA1C 8.5%. ওনার প্রায় ডায়াবেটিস uncontrolled থাকে, গত ১৫ দিন থেকে ওনার পায়ে ঝিমঝিম করে, সাথে painful burning sensation.

What is Dx and Rx?

Answer —

Dx- Diabetic Neuropathy

এখন যা করতে হবে-

১.. ডায়াবেটিস কন্ট্রোল করতে হবে, প্রয়োজনে ডায়াবেটিস এর ড্রাগ এর ডোজ এডজাস্ট কর‍তে হবে.

২.. numbness and pain relief এর জন্য Pain modulators দিতে হবে,

নিম্নের ৪ টা পেইন মডুলেটর থেকে যে কোনো একটা দিয়ে শুরু করতে পারেন,

1. Pregabalin

2. Gabapentin

3. Duloxetine

4..Amitriptyline

মনে রাখার টেকনিক — PG in D/A

Pregabalin সবচেয়ে পাওয়ারফুল-

Initially 50 mg once Daily দিয়ে শুরু করবে,

তবে পেইন কমতে সাধারণত 75 mg BD তে যাওয়া লাগবে

পেশেন্টের dizziness হতে পারে, তাই শুরুতে কয়েকদিন

Capsule 1:-Pregaba 25 mg (AS A Pregabalin As a Adjunct anti-epileptic drugs, Primary anti-epileptic drugs.)

Indications Of Capsule :-Pregaba 25 mg (AS A Pregabalin As a Adjunct anti-epileptic drugs, Primary anti-epileptic drugs.)

Pregaba film-coated tablet is indicated for:

Neuropathic pain associated with diabetic peripheral neuropathy
Postherpetic neuralgia
Adjunctive therapy for the treatment of partial-onset seizures in patients 1 month of age and older
Fibromyalgia
Neuropathic pain associated with spinal cord injury

Pregaba controlled release tablet is indicated for:

Neuropathic pain associated with diabetic peripheral neuropathy
Postherpetic neuralgia

Pharmacology Of Capsule :-Pregaba 25 mg (AS A Pregabalin As a Adjunct anti-epileptic drugs, Primary anti-epileptic drugs.)

Pregabalin is a structural derivative of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). It does not bind directly to GABA_A, GABA_B or benzodiazepine receptors. Pregabalin binds with high affinity to the alpha2-delta site (an auxiliary subunit of voltage-gated calcium channels) in central nervous system tissues. Although the mechanism of action of Pregabalin has not been fully elucidated, results in animal studies suggest that binding to the alpha2-delta subunit may be involved in Pregabalin’s anti-nociceptive and antiseizure effects.

Side Effects Of Capsule :-Pregaba 25 mg (AS A Pregabalin As a Adjunct anti-epileptic drugs, Primary anti-epileptic drugs.)

Most common side effects in adults are dizziness, somnolence, dry mouth, edema, blurred vision, weight gain and thinking abnormal (primarily difficulty with concentration/attention). Most common side effects in pediatric patients for the treatment of partial onset seizures are increased weight and increased appetite.

Tablet 2:-Gabastar 300mg (As a Gabapentin As a Adjunct anti-epileptic drugs).

Indications of Tablet :-Gabastar 300mg (As a Gabapentin As a Adjunct anti-epileptic drugs).

Gabastar is indicated for-

Neuropathic Pain.
Adjunctive therapy in partial seizure and secondary generalized seizure.

Pharmacology of Tablet :-Gabastar 300mg (As a Gabapentin As a Adjunct anti-epileptic drugs).

Gabapentin is an anti-convulsant. It is a structural analog of gamma-amino-butyric-acid (GABA). All pharmacological actions following administration of Gabapentin are due to the activity of parent compound. Gabapentin binds with the alpha-2-delta subunit of voltage gated L-type Calcium channel, and inhibits branched chain amino acid transferase & probably inhibits neurotransmitter release of excitatory amino acid.

Side Effects of Tablet :-Gabastar 300mg (As a Gabapentin As a Adjunct anti-epileptic drugs).

Fatigue, Dizziness, ataxia, weight gain, peripheral edema, dry mouth and somnolence may occur.

Capsule 3:-Diliner DR (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)).

Indications of Capsule :-Diliner DR (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)).

Diliner DR is a serotonin and norepinephrine reuptake inhibitor (SNRI) indicated for-

Major Depressive Disorder (MDD)
Generalized Anxiety Disorder (GAD)
Diabetic Peripheral Neuropathic Pain (DPNP)
Fibromyalgia and
Chronic Musculoskeletal Pain.

Pharmacology of Capsule :-Diliner DR (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)).

Duloxetine Hydrochloride is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) for oral administration. Duloxetine is a less potent inhibitor of dopamine reuptake. Duloxetine has no significant affinity for dopaminergic, adrenergic, cholinergic, histaminergic, opioid, glutamate, and GABA receptors in vitro. Duloxetine does not inhibit monoamine oxidase (MAO). Orally administered Duloxetine hydrochloride is well absorbed. Elimination of Duloxetine is mainly through hepatic metabolism.

Side Effects of Capsule :-Diliner DR (As a Duloxetine Hydrochloride As a Serotonin-norepinephrine reuptake inhibitor (SNRI)).

The most commonly observed adverse events in Diliner DR treated patients were nausea, dizziness, dry mouth, constipation, decreased appetite, fatigue, somnolence, increased sweating, hyperhidrosis and asthenia. It may slightly increase blood pressure. No clinically significant differences were observed for QT, PR, and QRS intervals between Diliner DR-treated and placebo-treated patients.

Tablet 4.Amilin 25 mg (As a Amitriptyline Hydrochloride AS a Tricyclic Anti-depressant.)

Indications of Tablet .Amilin 25 mg (As a Amitriptyline Hydrochloride AS a Tricyclic Anti-depressant.):-

Amilin is indicated in-

Depressive Illness: particularly where sedation is required.
Nocturnal Enuresis in children.
Prophylaxis of Migraine.
Tension Headache.
Chronic Pain.

Pharmacology of Tablet .Amilin 25 mg (As a Amitriptyline Hydrochloride AS a Tricyclic Anti-depressant.):-

The mechanism of action of this drug is not fully elucidated. It is suggested that amitriptyline inhibits the membrane pump mechanism responsible for the re-uptake of transmitter amines, such as norepinephrine and serotonin, thereby increasing their concentration at the synaptic clefts of the brain. These amines are important in regulating mood. The monoamine hypothesis in depression, one of the oldest hypotheses, postulates that deficiencies of serotonin (5-HT) and/or norepinephrine (NE) neurotransmission in the brain lead to depressive effects. This drug counteracts these mechanisms, and this may be the mechanism of amitriptyline in improving depressive symptoms.

Side Effects of Tablet .Amilin 25 mg (As a Amitriptyline Hydrochloride AS a Tricyclic Anti-depressant.):-

Anticholinergic: Excessive perspiration, dry mouth, blurred vision, hyperpyrexia, urinary retention and urinary tract dilatation.
Cardiovascular reactions: Hypotension, syncope, postural hypotension, hypertension, tachycardia, palpitations, myocardial infarction, etc.
CNS and Neuromuscular: Confusional states, disturbed concentration, disorientation, delusions, etc.
Allergic: Skin rash, urticaria, photosensitization, etc.
Haematological: Bone-marrow depression.
Gastrointestinal: Nausea, epigastric distress, vomiting, anorexia, stomatitis, unpleasant taste, weight loss, diarrhoea, constipation, etc.
Endocrine: Testicular swelling, gynaecomastia, breast enlargement, galactorrhoea, etc.

0+0+1 (5 days)

1+0+1 (5 days)

Then Pregaba 50 mg

1+0+1 (observe 4 weeks, if pain decrease then continue, otherwise

Pregaba 75 mg

1+0+1 (এই ক্ষেত্রে পেইন কমে যাবে)

৪ সপ্তাহে না কমলে অন্য একটা তে switch করবে।

খুব বেশি পেইন হলে Tramadol দেওয়া যাবে অল্প কয়েক দিনের জন্য।

Tablet 5:-Anadol SR 100mg (As a Tramadol Hydrochloride As a Opioid analgesics).

Indications of Tablet :-Anadol SR 100mg (As a Tramadol Hydrochloride As a Opioid analgesics):-

Anadol SR is used for the treatment of moderate to severe painful conditions. These include:

Postoperative pain
Colic and spastic pain
Cancer pain
Joint pain
Neck and back pain
Pain associated with osteoporosis.

Pharmacology of Tablet :-Anadol SR 100mg (As a Tramadol Hydrochloride As a Opioid analgesics):-

Tramadol is a centrally acting synthetic analgesic compound. It inhibits the re uptake of neurotransmitters- serotonin and noradrenaline. Thus it modifies the transmission of pain impulses by activating both descending serotonergic pathways and noradrenergic pathways involved in analgesia. The analgesic effects of Tramadol are mediated via stimulation of mu-opioid receptors and indirect modulation of central monoaminergic inhibitory pathways.

Side Effects of Tablet :-Anadol SR 100mg (As a Tramadol Hydrochloride As a Opioid analgesics):-

Commonly occurring side-effects are dizziness/vertigo, nausea, constipation, headache, somnolence, vomiting, pruritus, CNS stimulation, asthenia, sweating, dyspepsia, dry mouth, diarrhoea. Less commonly occurring side-effects include malaise, allergic reaction, weight loss, vasodilatation, palpitations, abdominal pain, anorexia, flatulence, GI bleeding, hepatitis, stomatitis etc.

আর পেইন যদি localised হয়, (post herpetic neuralgia) হলে Capsaicin cream দেওয়া যাবে.

চলবে-

Cream 6:-Topicacin 0.025%w/w 20gm tube (As a Capsaicin As a Topical Analgesics, Topical anti-inflammatory preparations).

Indications of Cream :-Topicacin 0.025%w/w 20gm tube (As a Capsaicin As a Topical Analgesics, Topical anti-inflammatory preparations).

Topicacin is indicatd for- Rheumatoid arthritis, Osteoarthritis, Pain due to diabetic neuropathy, Joint pain, Post-herpetic neuralgia, Post-surgical neuropathic pain, Nerve Pain, Back pain, Muscle pain, Fibromyalgia, Bursitis, Pruritis (itching)

Pharmacology Cream :-Topicacin 0.025%w/w 20gm tube (As a Capsaicin As a Topical Analgesics, Topical anti-inflammatory preparations).

Although the precise mechanism of action of Capsaicin is not fully understood, current evidence suggests that Capsaicin exerts an analgesic effect by depleting and preventing reaccumulation of Substance P in peripheral sensory neurons. Substance P is thought to be the principal chemomediator of pain impulses from the periphery to the central nervous system.

Side Effects Cream :-Topicacin 0.025%w/w 20gm tube (As a Capsaicin As a Topical Analgesics, Topical anti-inflammatory preparations).

Topicacin may cause transient burning on application. This burning is observed more frequently when the application schedules are more than 3-4 times daily. The burning can be enhanced if too much cream is used and if it is applied just before or after a bath or shower.

General Queries:-

1.vaia,capsaicin cream ar dose interval koto hobe?

Answer is:-

2-3 times daily for 1 month.

Raiyyan Tahsan Date:-25-12-2024 Wednesday Time:8.46.30 Pm.

Raiyyan Tahsan

Raiyyan Tahsan