Reactions 1680, p336 - 2 Dec 2017 Madden K, et al. Very-Low-Dose Methadone to Treat Refractory Neuropathic Pain in Children with Cancer. Journal of Palliative Medicine 20: 1280-1283, No. 11, Nov 2017. Available from: URL: http://doi.org/10.1089/jpm.2017.0098 - USA 803284858 Refractory neuropathic pain and insomnia: 2 case reports A 19-month-old boy developed insomnia secondary to refractory neuropathic pain and a 6-year-old boy developed refractory neuropathic pain, during therapy with vincristine for acute lymphoblastic leukaemia (ALL) [routes and times to reaction onset not stated; not all dosages stated]. Patient 1: The 19-month-old boy, who had been receiving vincristine 0.75 mg/m body surface area, presented for insomnia to a paediatric supportive care. He reportedly had difficulty in maintaining sleep. After sleeping, he would wake approximately at 60 minutes and later had to be consoled and massaged by parents. He would sleep 90–120 minutes, but again the cycle would repeat. He did not have any problems in day time sleep. He received treatment with lorazepam 0.05 mg/kg/dose for two doses and diphenhydramine 0.1 mg/kg/dose for three doses but were stopped because of a paradoxical reaction. With a presumptive diagnosis of insomnia, treatment with olanzapine was initiated but it did not improve the symptoms and therefore was discontinued. At follow up, the parents reported that the boy did not like to wear pajama bottom at night and cried because of pain. There was a notable delay in the gross motor skill of walking despite receiving physical therapy. He had developed insomnia secondary to neuropathic pain from vincristine. Hence, amitriptyline was started and added to the child’s gabapentin therapy. However no clinical benefit was observed after two weeks. Afterwards. he was started on treatment with very low dose methadone. Within three days, his sleep improved as there were fewer awakenings, and time awake was shorter. Within seven days, he slept through the night and started to walk without any help. He also started to allow his mother to place full length pajamas on him, and cover him with a blanket at night. Four months after starting methadone, he continued to have low scores of pain, fatigue, and insomnia. A brief increase in pain was noted after weaning of gabapentin therapy which reduced following dose adjustments. A year after methadone therapy, he completed vincristine therapy. Gabapentin and methadone were weaned off over a six-week period time with no recurrence of pain. Patient 2: The 6-year-old boy with ALL had been receiving treatment with chemotherapy including vincristine. He had a one year history of vague pain in legs and back, which was presumed to be neuropathic pain. He was treated with gabapentin at 45 mg/kg/day, and morphine was added to treatment because of paroxysms of pain.As this treatment was not effective he presented to paediatric supportive care for the pain. He reportedly had pain in cervical, lower thoracic and lumbar spine, bilateral tibia, and fibulas. The pain was unpredictable and more common at night, and lasted 10–30 minutes. His parents used hot packs, cold packs, massage, acetaminophen, and morphine as treatment. He reported maximum pain intensity as 10/10 (Wong-Baker FACES scale) with baseline pain as 4/10. He described the pain as sharp with numbness/tingling. His was unable to play sports and comfortably sit in a car for longer than two hours. His physical examination showed diminished pain and light touch discrimination at the level of the bilateral mid-tibia to feet. Subsequently, a diagnosis of refractory neuropathic pain was made. He was initiated on very low dose methadone. Four months after initiation of methadone, he showed continued low scores of pain, fatigue, and insomnia. His morphine dose was reduced in the first month of methadone therapy. After three months, he was able to tolerate a 15 hour car trip. One year later, he was on the same dose of methadone with continued low scores for pain and fatigue. Therapy with vincristine was maintained. Author comment: "Vincristine is known to cause peripheral neuropathy that is associated with pain." 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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