Brief Answer:
Many thanks for your kind words of confidence and appreciation

Detailed Answer:
I've reviewed your additional questions and am sorry to hear that your current physician has inherited a situation whereby he is now expected to use and adjust dosing of this medication in order to help you with your problems. This is a most unenviable position for your treating physician. Though the following comment is not something you are directly asking about- perhaps you'll indulge me a moment. But if I were in your treating doctor's position of not being familiar with the medication you have been placed on I would consider doing 1 of 2 things:

1. I would make a referral as the primary physician to a pain management specialist OR Neurologist due to my own limitations as a prescriber. I do realize that Canada's Healthcare System has its issues but I'm sure if the PMD himself initiated the consult request on the basis of MEDICAL NECESSITY then, you stand a good chance of being expeditiously sent to the right set of hands to manage the Lyrica.

2. I would look to SWITCH YOU TO AN AGENT which is potentially equivalent and similar in its pain management potential for the types of symptoms you have which is also something that I was familiar and comfortable with prescribing and manipulating. I understand that you have found a measure of relief, however, using this on a long term basis with a physician who is not familiar with the medication I believe is a recipe for complications in the future that may not always be solvable in the way we seem to be handling this particular case. Don't you agree?

Again, please excuse my diversion in bringing those issues up, however, I believe they are relevant and important points for you and he to consider going forward since it's your health which is at stake as well as the doctor's obligation to make sure he has provided you the best possible environment to care for your issues (INCLUDING the safe and optimal use of your pharmacological regimen).

I will now proceed to answer your specific questions and to also make a brief clarification or 2 of things that you've written regarding my last post on the use of Lyrica (pregabalin).

First the clarification....my advice to raise the 600mg. per day is purely based upon those of the manufacturer and the most likely move I would make in MOST PATIENT ENCOUNTERS assuming there were no other reasons to stay at a lower dose adding an increased frequency or adjuvant drug/intervention such as acupuncture, biofeedback, aquatherapy, off label BOTOX injections for neuropathic pains, etc. etc.

In other words, I typically will not make a decision to change medication doses in my own patients until I'm fully satisfied that one is needed and warranted. This usually comes after follow up visits where I am able to see and exam the patients face to face. I never authorize changes of medications or doses by phone, email, or text messaging though I communicate with my patients using all those formats and more. Make sense?

Feeling tired is a known consequence of using medications that control pain (in general no matter what the class) and so long as it doesn't materially interfere with your daily activities, work, or home life then, this is usually considered acceptable to most people IF THEY ARE RECEIVING satisfactory benefits.

Your second question is trickier to answer since I've since some of the strangest things in patients when applying frequency variations of a medication for not only pain management but other neurological conditions making impossible to accurately predict how any individual (such as yourself) might respond before actually implementing the change and seeing the results. I can tell you that the MOST COMMON dosing frequency I use in my patients is what the manufacturer recommends which is TWICE DAILY. Only in special cases will I stray from this recommendation and I can't really describe to you exactly what those criteria may be except to say that when I SEE and EXAMINE a patient who comes to me stating that the usual protocol isn't working...well, then I know I may be dealing with someone who may need an "outside the box" approach.

After reviewing the list of medications and even BOTOX which you've trialed I can understand your feeling that you've been "on every sort and class of medication known to man"....but for example, just in the regimen listed I see that gabapentin was only tried as 300mg. once daily briefly. Amitriptyline (but not Nortriptyline or any other TCA) was only tried up to a maximum 50mg. and only for 4 weeks. In my estimation those are inadequate trials for those drugs unless you suffered intolerable side effects or drug to drug interactions that required they be retired immediately. There are a number of other agents such as PHENYTOIN, CARBAMAZEPINE, and OXCARBAZEPINE which I don't see listed and these are common employed in neuropathic pain management.

Your case sounds fascinating in terms of the problem you have that nobody has been able to really figure out leading me to believe that there is the lack of a GROUNDED DIAGNOSIS. You have just a symptom of throat pain/soreness which is being chased down but what's the cause? There are other ways to investigate this sort of symptom complex but again, within the Canadian Health Care System, all facets of diagnostics that are possible to look at such a problem may not have been utilized due to prohibitive cost or lack of availability....not sure if that's applicable in your case.

If you would like to consider the possibility of traveling to XXXXXXX OH which is not that far across the border I would be happy to take a fresh look at this problem using an interdisciplinary team of specialists who could also opine as to what may or may not be going on notwithstanding what diagnostic tests have shown to date. I believe the long term benefit to you of obtaining a DIAGNOSIS can pay huge dividends since TACHYPHYLAXIS (resistance) to Lyrica is just as likely to happen in the future as it already seems to have happened with other drugs you've listed. I'm almost certain that YOU WOULD LOVE to know what is causing this problem in the first place, n'est ce pas?

How much more satisfying might it be from a personal as well as MEDICAL point of view to ESTABLISH A DIAGNOSIS (possibly even discovering the underlying cause) to this rather unusual form of pain instead of taking a short term approach of "control the symptom" as you said above? This approach (though feasible in the short run) has a finite duration of time before something else would have to be attempted- Not to mention the strain on your body which has thus-far been exposed to a plethora of substances (i.e. chemically formulated agents using ingredients and compounds that could cause toxicity to the body)?

As in the previously answered question I've done my best to give you the best medical answers possible to a difficult situation for which only symptoms without a cause are present. Therefore, I hope I've given you useful information to contemplate along with your medical provider and would greatly appreciate your kind feedback as well as the closure of the query?

Please write to me if other questions or comments arise at: www.bit.ly/drdariushsaghafi and I will gladly answer. Also, if you would like to consider being seen at Parma Neurology let me know and I would be happy to provide details.

This query has utilized 60 min. of research and response time on behalf of this patient.

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