Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm.

Importance: Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. Objective: To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. Design, Setting, and Participants: This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). Exposures: After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Main Outcomes and Measures: Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. Results: A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. Conclusions and Relevance: In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

Impact of methocarbamol on opioid use after ventral incisional hernia repair.

BACKGROUND: Alternatives to opioid analgesia are needed to reduce the risk of abuse, misuse, and diversion. Musculoskeletal pain is a significant contributor to postoperative pain after ventral hernia repair (VHR). We report the impact of methocarbamol on opioid prescribing after VHR. METHODS: Review of all robotic and open VHR, Jan 2020-July 2022. Data was collected in the Abdominal Core Health Quality Collaborative (ACHQC) with additional chart review to assess for opioid refills. A 2:1 propensity score match was performed comparing opioid prescribing in patients prescribed vs not prescribed methocarbamol. RESULTS: 101 patients received methocarbamol compared with 202 without. Similar number of patients received an opioid prescription (87.1 vs 86.6%; p = 0.904). Study patients received significantly lower MME prescription at discharge (60 v 75; p = 0.021) with no difference in refills (12.5 vs 16.6%; p = 0.386). CONCLUSION: Addition of methocarbamol to a multimodal analgesic regimen after VHR facilitates reduction in prescribed opioid with no increase in refills.

Impact of methocarbamol on opioid use after primary ventral and inguinal hernia repair.

BACKGROUND: Multimodal analgesia is now a mainstay of perioperative care. Our aim is to assess the impact of adding methocarbamol on opioid use for patients undergoing primary ventral (umbilical and epigastric) hernia repair (PVHR) and inguinal hernia repair (IHR). METHODS: Retrospective review of patients undergoing PVHR and IHR who received methocarbamol, propensity score matched in a 2:1 fashion to patients not receiving methocarbamol. RESULTS: Fifty-two PVHR patients receiving methocarbamol were matched to 104 control patients. Study patients were prescribed fewer opioids (55.8 vs 90.4%; p < 0.001) and received lower MME (20 vs 50; p < 0.001), with no difference in refills or rescue opioids. For IHR, study patients received fewer prescriptions (67.3 vs 87.5%; p < 0.001) and received lower MME (25 vs 40; p < 0.001), with no difference in rescue opioid (5.9 vs 0%; p = 0.374). CONCLUSIONS: Methocarbamol significantly reduced opioid prescribing in patients undergoing PVHR and IHR without increasing the risk of refill or rescue opioid.

Association Between Postoperative Methocarbamol and Postoperative Pain Opioid Dose Requirements: A Retrospective Cohort Study.

OBJECTIVES: We tested the hypothesis that patients who received methocarbamol postoperatively experience less severe pain and require smaller doses of opioids than those who did not receive methocarbamol. MATERIALS AND METHODS: This is a retrospective cohort study of patients undergoing surgery involving the musculoskeletal system. Of 9089 patients, 704 received methocarbamol during 48 hours postoperatively, while 8385 did not receive methocarbamol. The patients who received methocarbamol postoperatively and the patients who did not receive methocarbamol were compared on the time-weighted average (TWA) pain score and opioid dose requirements in morphine milligram equivalents (MME) during the first 48 hours postoperatively, using propensity score-weighted regression models to adjusting for preoperative and intraoperative covariates. RESULTS: Postoperative 48-hour TWA pain scores were 5.5±1.7 (mean±SD), and 4.3±2.1 for methocarbamol and non-methocarbamol patients. Postoperative 48-hour opioid dose requirements in MME were 276 [170-347] (median [interquartile range (IQR)]) mg, and 190 [60-248] mg for methocarbamol and non-methocarbamol patients. In propensity score-weighted regression models, receiving methocarbamol postoperatively was associated with 0.97-point higher postoperative TWA pain score (95% CI, 0.83-1.11; P <0.001), and 93.6-MME higher postoperative opioid dose requirements (95% CI, 79.9 to 107.4; P <0.001), compared with not receiving methocarbamol postoperatively. DISCUSSION: Postoperative methocarbamol was associated with significantly higher acute postoperative pain burden and opioid dose requirements. Although the results of the study are influenced by residual confounding, they suggest a limited-if any-benefit of methocarbamol as an adjunct of postoperative pain management.

Methocarbamol versus diazepam in acute low back pain in the emergency department: a randomised double-blind clinical trial.

BACKGROUND: Acute low back pain (LBP) is a common complaint in the emergency department and achieving effective analgesia can be challenging. METHODS: In this multicentre randomised double-blind clinical trial conducted at three EDs in Iran from August to November 2020, we assessed the efficacy and adverse effects of two muscle relaxants in patients aged 18 years or older who suffered LBP in the last 6 weeks. Group 1 received intravenous methocarbamol and group 2 received intravenous diazepam followed by a weight-based dose of intravenous morphine in both groups. Exclusion criteria mainly included non-spine aetiologies, cord compression, acute gastrointestinal bleeding, renal/hepatic insufficiency, pregnancy, breast feeding and unstable vital signs. Pain scores and adverse events were measured by a Numeric Rating Scale (NRS) at baseline and after 30 and 60 min by one of the researchers who was not involved with patient visits and was blinded to the intervention. We used t-test to assess the mean difference of NRS at 30 and 60 min. RESULTS: Out of 101 enrolled patients, 50 participants received methocarbamol and 51 diazepam. The baseline mean pain scores and demographic characteristics were not different between the study groups. Pain scores were reduced by both agents after 60 min, with slightly greater pain reductions in the diazepam group in comparison with methocarbamol (mean difference -6.1, 95% CI -6.5 to -5.7 vs mean difference -5.2, 95% CI -5.7 to -4.7, respectively, p<0.001). ED length of stay of patients did not differ between the groups (methocarbamol 5.9 vs diazepam 4.8 hours, p=0.365). Patients receiving diazepam were more likely to report drowsiness (2 (4.0%) vs 15 (29.4%), p=0.001). CONCLUSIONS: In patients with LBP, the pain was relieved in the methocarbamol and diazepam groups after 60 min. Although diazepam was more effective, its use was associated with a slightly higher risk of drowsiness. TRIAL REGISTRATION NUMBER: The protocol of this clinical trial was prospectively registered in the irct.ir (IRCTID: IRCT20151113025025N4; https://irct.ir/trial/50148) .

Identifying Clinically Relevant Drug-Drug Interactions With Methadone and Buprenorphine: A Translational Approach to Signal Detection.

Methadone and buprenorphine have pharmacologic properties that are concerning for a high risk of drug-drug interactions (DDIs). We performed high-throughput screening for clinically relevant DDIs with methadone or buprenorphine by combining pharmacoepidemiologic and pharmacokinetic approaches. We conducted pharmacoepidemiologic screening via a series of self-controlled case series studies (SCCS) in Optum claims data from 2000 to 2019. We included persons 18 years or older who experienced an outcome of interest during target drug treatment. Exposures were all overlapping medications (i.e., the candidate precipitants) during target drug treatment. Outcomes were opioid overdose, non-overdose adverse effects, and cardiac arrest. We used conditional Poisson regression to calculate rate ratios, accounting for multiple comparisons with semi-Bayes shrinkage. We explored the impact of key study design choices in analyses that varied the exposure definitions of the target drugs and the candidate precipitant drugs. Pharmacokinetic screening was conducted by incorporating published data on CYP enzyme metabolism into an equation-based static model. In SCCS analysis, 1,432 events were included from 248,069 new users of methadone or buprenorphine. In the primary analysis, statistically significant DDIs included gabapentinoids with either methadone or buprenorphine; baclofen with methadone; and benzodiazepines with methadone. In sensitivity analysis, additional statistically significant DDIs included methocarbamol, quetiapine, or simvastatin with methadone. Pharmacokinetic screening identified two moderate-to-strong potential DDIs (clonidine and fluconazole with buprenorphine). The combination of clonidine and buprenorphine was also associated with a significantly increased risk of opioid overdose in pharmacoepidemiologic screening. These DDI signals may be the most important targets for future confirmation studies.

The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies.

BACKGROUND: Low back pain (LBP) causes 2.6 million visits to U.S. emergency departments (EDs) annually. These patients are often treated with skeletal muscle relaxants (SMRs). OBJECTIVES: The goal of this study was to determine whether efficacy of SMRs is associated with age, sex, or baseline LBP severity. METHODS: This was a planned analysis of data from 4 randomized studies of patients with acute nonradicular LBP. Patients were enrolled during an ED visit and followed-up 1 week later. The primary outcome was improvement in the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and the 1-week follow-up. We compared the change in RMDQ among 8 groups: placebo, baclofen, metaxalone, tizanidine, diazepam, orphenadrine, methocarbamol, and cyclobenzaprine. All patients also received a nonsteroidal anti-inflammatory drug. We performed analysis of variance to determine statistically significant differences between medications and linear regression to determine the association of age, sex, and baseline severity with the primary outcome. RESULTS: The mean improvement in RMDQ per group was placebo 10.5 (95% confidence interval [CI] 9.5-11.5), baclofen 10.6 (95% CI 8.6-12.7), metaxalone 10.3 (95% CI 8.1-12.4), tizanidine 11.5 (95% CI 9.5-13.4), diazepam 11.1 (95% CI 9-13.2), orphenadrine 9.5 (95% CI 7.4-11.5), methocarbamol 8.1 (95% CI 6.1-10.1), and cyclobenzaprine 10.1 (95% CI 8.3-12). The between-group differences were not statistically significantly different. Results were similar regardless of age, sex, and baseline severity. Higher baseline RMDQ was associated with greater clinical improvement (B coefficient 5.7, p < 0.01). Adverse medication effects were more common with cyclobenzaprine than with placebo (p < 0.01). CONCLUSIONS: Among patients in the ED with acute LBP treated with a nonsteroidal anti-inflammatory drug, SMRs do not improve outcomes more than placebo. Neither age, sex, nor baseline impairment impacts these results.

Rapid transition from methadone to buprenorphine using naltrexone-induced withdrawal: A case report.

Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.

Randomized-controlled trial of methocarbamol as a novel treatment for muscle cramps in cirrhotic patients.

BACKGROUND: Muscle cramps occur in 29-88% of patients with liver cirrhosis. They adversely affect quality of life. This study aimed to evaluate the efficacy and safety of methocarbamol as a novel therapy in controlling muscle cramps in cirrhotic patients. PATIENTS AND METHODS: This study was carried on 100 patients with liver cirrhosis in addition to chronic hepatitis C who presented with frequent muscle cramps (≥three cramps per week). Half of these patients received methocarbamol and the other half received placebo. This was done through equal randomization. Questionnaires on muscle cramp were answered. Patients were evaluated before, after 1 month of treatment, and 2 weeks after washout of treatment in terms of severity, duration, and frequency of cramps. Liver, renal functions, and electrolytes were analyzed. Also, any side effect was detected. RESULTS: Patients who were treated with methocarbamol showed a significant decrease in the frequency and duration of cramps. Also, the pain score improved significantly. However, no significant changes were observed in the placebo group. Few side effects of methocarbamol were recorded, including dry mouth and drowsiness. CONCLUSION: Methocarbamol seems to be a promising safe and well-tolerated medication, and plays a role in the treatment of muscle cramps in patients with liver cirrhosis.

[Real-life efficacy and tolerability of methocarbamol in patients suffering from refractory muscle-related low/back pain - Results of a health care research project based on data from the German pain practice registry]. / Wirksamkeit und Verträglichkeit von Methocarbamol bei muskulär bedingten subakuten Kreuz-/Rückenschmerzen : Ergebnisse eines Versorgungsforschungsprojektes unter Verwendung von Daten des DGS-PraxisRegister Schmerz.

BACKGROUND: Subacute, muscle-related low/back pain (L/BP) is known to be difficult to treat and frequently requires more specific causal-oriented treatments with agents improving the increased muscle tone. Currently, only methocarbamol is approved and available for the 1st-line treatment of patients with muscle-related L/BP in Germany - however, without sufficient data on longer lasting effects (> 1 week) in elsewhere refractory patients. METHOD: Noninterventional cohort study, based on anonymized routine data of the German pain practice registry; retrospective evaluation of patients with refractory L/BP, who first time received a treatment with methocarbamol between October 1st until December 31st, 2015, and who documented their response to treatment with the standardized and validated instruments of the German pain questionnaire over at least 4 weeks (n = 251 patients). RESULTS: During the 4-week evaluation period, patients reported a highly significant and clinically relevant improvement of pain intensity (from 53.0 ± 10.5 to 19.0 ± 10.0 mm VAS), pain-related disability in daily life (mPDI: from 42.1 ± 12.5 to 15.5 ± 10.8) and quality of life (QLIP: from 18.6 ± 6.3 to 34.0 ± 5.5; all changes p < 0.001 vs. baseline). Corresponding 50% response rates were 81.7 (n = 205), 68.5 (n = 172) und 91.6 (n = 230) %. In parallel, lumbar mobility (measured with the Schober's test) improved from 10.7 ± 0.7 to 14.7 ± 0.7 cm (p < 0,001). Overall, seven patients recorded eight minor treatment-related adverse events, which all resolved spontaneously during treatment without any specific countermeasures. CONCLUSION: Under the conditions of daily life, patients with elsewhere refractory L/BP reported a significant and clinically relevant improvement of pain intensity, pain-related disability and quality of life in response to a 4-week treatment with methocarbamol.

Multimodal Drug Therapy and Physical Rehabilitation in the Successful Treatment of Capture Myopathy in a Lesser Flamingo (Phoeniconaias minor).

A wild-caught lesser flamingo (Phoeniconaias minor) from the Fort Worth Zoo (Fort Worth, TX, USA) presented with moderate lameness that progressed to the inability to stand 2 days after restraint and handling. Results of blood tests showed severely elevated creatine phosphokinase (CPK) and aspartate aminotransferase (AST) activities, confirming suspected capture myopathy. Intensive supportive therapy, consisting of intravenous fluids and muscle relaxants, along with physical rehabilitation therapy, nutritional support, and anxiolytics, were instituted to aid in relaxation and muscle regeneration. After 2 weeks of intensive therapy, the bird showed substantial improvement and could remain standing throughout the day after being assisted to a standing position. By day 23, the bird was able to stand independently and walk completely unassisted, with no discernible lameness. The bird has subsequently remained healthy since it was returned to the flock approximately 27 days after it was first presented for treatment. Although anecdotal communications of successful treatment of this condition in flamingos exist, this is the first report, to our knowledge, that describes in detail the successful treatment of capture myopathy in any flamingo species. Success in this case is attributed to the combination of early fluid and drug therapy, intensive physical rehabilitation therapy, and anxiolytics to counteract the hyperexcitable nature of this wild-caught bird.

Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures.

BACKGROUND: The objective of this study was to evaluate the effect of methocarbamol on hospital length of stay in patients with closed rib fracture injuries. METHODS: This was a retrospective cohort study conducted in an academic medical center in the United States. Adult trauma patients, who sustained closed rib fractures, were included. Patients were categorized based on whether they received methocarbamol or not during admission. The primary outcome of interest was time to hospital discharge in days (i.e. length of hospital stay). A Cox Proportional Hazards Model was constructed to determine if methocarbamol use was associated with a greater likelihood of earlier discharge. RESULTS: A total of 592 patients were included in the final study cohort. Of these, 329 received methocarbamol and 263 did not receive methocarbamol. In the Cox Proportional Hazards Model methocarbamol use was associated with a greater likelihood of being discharged from the hospital (HR 1.47, 95% CI 1.21 to 1.78, p < 0.001). . CONCLUSIONS: The use of methocarbamol after traumatic rib fractures may result in a reduction in the length of hospital stay.

Effect of Methocarbamol on Acute Pain After Traumatic Injury.

There is interest in the use of methocarbamol as an adjunctive agent for pain control after traumatic injury. The primary objective of this study was to determine the effect of methocarbamol on pain measurements after acute injury. This was a retrospective, matched cohort study conducted at an academic medical center in the United States. Consecutive adult (age ≥18 years) patients who were admitted to the hospital between June 1, 2012 and June 30, 2013 because of a traumatic injury were evaluated. Patient cases receiving methocarbamol for at least 3 days were matched to controls that did not receive methocarbamol based on age, sex, and injury severity. The primary outcome measures of pain scores were assessed on numerical rating scale from 0 to 10 (0 = no pain; 10 = worst possible pain) and conducted during routine patient care. A total of 200 patients were included in the final cohort (100 in each group). In the overall cohort, the mean age was 49 ± 22 years, 67% were men, and mean International Classification of Disease-derived Injury Severity Score was 0.8 ± 0.1 in both groups. There was no significant association between methocarbamol use and mean pain score on day 1 [coefficient 0.09, 95% confidence interval (CI), -0.57 to 0.75, P = 0.782, model R = 0.43], day 2 (coefficient 0.47, 95% CI, -0.15 to 1.09, P = 0.140, model R = 0.42), or day 3 (coefficient 0.51, 95% CI, -0.13 to 1.16, P = 0.117, model R = 0.42) after injury. Methocarbamol did not improve pain control after traumatic injury during the first 3 days of hospitalization.

Successful treatment of Solanum dulcamara intoxication in a Labrador retriever puppy.

A 10-week-old intact male Labrador retriever dog was presented for acute onset of weakness, ataxia, and generalized muscle tremors. The puppy was suffering respiratory and central nervous system (CNS) depression, was mildly pyrexic, and vomited plant material that was identified as creeping nightshade (Solanum dulcamara). He responded well to supportive care and was discharged successfully. To the authors' knowledge, this is the first report of Solanum dulcamara toxicity occurring in a dog.

Traitement réussi d'une intoxication parSolanum dulcamarachez un chiot Labrador retriever. Un chien Labrador retriever mâle intact âgé de 10 semaines a été présenté pour l'apparition aiguë de faiblesse, d'ataxie et des tremblements musculaires généralisés. Le chiot souffrait d'une dépression du système respiratoire et du système nerveux central (SNC), présentait une pyrexie légère et vomissait du matériau végétal qui a été identifié comme étant de la morelle douce-amère (Solanum dulcamara). Il a bien répondu à des soins de soutien et a reçu un congé pour un traitement réussi. À la connaissance des auteurs, c'est le premier rapport d'une toxicité de Solanum dulcamara se produisant chez un chien.(Traduit par Isabelle Vallières).

[Methocarbamol in acute low back pain. A randomized double-blind controlled study]. / Methocarbamol bei akuten Rückenschmerzen : Eine randomisierte, doppelblinde, placebokontrollierte Studie.

BACKGROUND: Muscle relaxants are widely used to treat low back pain (LBP), one of the most frequent health problems in industrialized countries. For this indication, the European Medicines Agency (EMA) recently had imposed restrictions for some muscle relaxants, anti-inflammatories and analgesics; Tetrazepam even had to be withdrawn from the market. Therefore methocarbamol remains the only approved muscle relaxant. Methocarbamol is well-established for the treatment of LBP associated with myofascial components, although more recent clinical studies have not been published. Therefore this publication summarizes and revaluates post-hoc data of an efficiency study of methocarbamol, that was performed in 2002, but had not been published yet. METHOD: This was a randomized, placebo controlled multi-centre study. Inclusion criteria were acute low back pain for at least 24 h associated with spasms in the pelvic/lumbar region and restriction of mobility. Patients were randomly assigned to a group treated with orally administered Ortoton® (n = 98) or placebo (n = 104). Drugs were administered for up to 8 days, but treatment of individual patients was discontinued as soon as a pain-free state was achieved. Individual pain perception was quantified by means of a visual analog scale (VAS). The fingertip-to-floor distance was measured as an indicator of lumbar flexion. Mobility restrictions were also assessed by a modified Schober's test. In addition, a questionnaire was used by patients and physicians to rate the efficacy of treatment. RESULTS: In the methocarbamol group 44% of the patients pre-terminated due to complete pain relief (placebo: 18%) and 19% discontinued because the treatment was considered ineffective (placebo 52%, p < 0,0001). Measures of mobility (fingertip-to-floor distance, Schober's test) and improvement of mobility as perceived by physician and patient at the individual end of study all were clearly in favor of the patients treated with methocarbamol. At the final visit, 67% of the patients who had received Ortoton® (35% of placebo patients) and 70% of their physicians (control group: 36%) considered the treatment to be effective. No severe adverse effects were observed during the study (7 symptoms in 5 patients). CONCLUSION: This study showed that methocarbamol, orally administered, is an efficient and well-tolerated therapeutic option for patients suffering from acute LBP and the typically associated restrictions of mobility.

Deep dry needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction.

BACKGROUND: To determine whether deep dry needling (DDN) of trigger points (TPs) in the lateral pterygoid muscle (LPM) would significantly reduce pain and improve function, compared with methocarbamol/paracetamol medication. MATERIAL AND METHODS: Forty-eight patients with chronic myofascial pain located in the LPM were selected and randomly assigned to one of two groups (DDN test group, n=24; drug-treated control group, n=24). The test group received three applications of needling of the LPM once per week for three weeks, while control group patients were given two tablets of a methocarbamol/paracetamol combination every six hours for three weeks. Assessments were carried out pre-treatment, 2 and 8 weeks after finishing the treatment. RESULTS: A statistically significant difference (p<0.05) was detected for both groups with respect to pain reduction at rest and with mastication, but the DDN test group had significantly better levels of pain reduction. Moreover, statistically significant differences (p<0.05) up to day 70 in the test group were seen with respect to maximum mouth opening, laterality and protrusion movements compared with pre-treatment values. Pain reduction in the test group was greater as a function of pain intensity at baseline. The evaluation of efficacy as assessed both by patients/investigators was better for the test group. 41% of the patients receiving the combination drug treatment described unpleasant side effects (mostly drowsiness). CONCLUSIONS: DDN of TPs in the LPM showed better efficacy in reducing pain and improving maximum mouth opening, laterality, and protrusion movements compared with methocarbamol/paracetamol treatment. No adverse events were observed with respect to DDN.

Adjunctive therapy with intravenous lipid emulsion and methocarbamol for permethrin toxicity in 2 cats.

OBJECTIVE: To describe the use of an intravenous lipid emulsion (ILE) as an adjunctive therapy in 2 cats with permethrin toxicity. CASE SERIES SUMMARY: Two cats that presented with severe permethrin toxicity were treated with ILE as part of their treatment regimens. Both cats improved dramatically following therapy with decontamination, ILE, methocarbamol, and supportive care. NEW OR UNIQUE INFORMATION PROVIDED: This is the first reported use of ILE as an adjunctive treatment for cats with permethrin toxicity. Outcome was favorable in both cats and no adverse effects were noted from the ILE.

Methocarbamol CRI for symptomatic treatment of pyrethroid intoxication: a report of three cases.

Pyrethroids are popular for use in companion animals due to their relatively low mammalian toxicity and efficacy against arthropods. Nonetheless, pyrethroid intoxication has been reported in cats and dogs, and cats appear to be more susceptible due to difficulty in biotransformation and excretion of pyrethroids. Pyrethroid intoxications are generally due to either the improper use or accidental ingestion of approved products. Methocarbamol, given as intermittent injections, is a common first-line treatment choice for the tremors associated with pyrethroid intoxication. Two cats and one dog were treated with a methocarbamol continuous rate infusion (CRI) for pyrethroid intoxication. Clinical signs of toxicity resolved within a few hr in all three cases, with no adverse drug effects. A methocarbamol CRI can be considered in animals presenting with pyrethroid intoxication.