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Southern Nevada Association of Polio Survivors
February 21st, 2015
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Viviana Cervantes, PharmD Candidate, Class 2015
Hodais Shooshtari, PharmD Candidate, Class 2015
Anna Wolf, PharmD Candidate, Class 2015
Preceptor:
Dr. Christina Madison, PharmD, BCACP, AAHIVP
Associate Professor of Pharmacy Practice
Roseman University of Health Sciences
Contact Information
Email: [email protected]
Phone: 702 759-1639
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Review Polio and Post-Polio syndrome (PPS)
Describe epidemiology PPS
Identify the signs and symptoms
Compare and contrast current treatment options both non-pharmacological and pharmacological
Discuss pain in PPS and current pain management
Provide a brief history of polio vaccines, what is currently available their significance
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Poliomyelitis or polio is a disease caused by the poliovirus
Affects the nervous system◦ Attacks the motor neurons in the spinal cord
◦ Causes localized inflammation in the nervous system
www.neuroanatomy.wisc.edu/SClinic/Weakness/Weakness/html
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wamu.org/programs/metro_connection/12/11/02/polio_survivor_and_doctor_chooses_new_path
Dr. Lauro Halstead introduced the term "post-polio syndrome" in 1986
Served at the MedstarHealth National Rehabilitation Hospital for 26 years
Specialized in spinal cord injury and post polio syndrome
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Contracted polio when he was 18 years old in Madrid, Spain
Survived on a plywood ventilator in the children's hospital run by nuns
Became a renowned physician
Treated polio patients and people with spinal cord injuries
http://www.npr.org/templates/story/story.php?storyId=103892252
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Only occurs in Polio survivors
Can affect polio survivors at any age
Results in the mild to moderate muscle weakness most commonly in the lower limbs
Affects people about 15 years or more after the initial polio attack
Not contagious
Not life-threatening
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Polio virus damages or destroys motor neurons
Compensating for the lost neurons, the survived neurons sprout new fibers
Results in a “recovery period”, with added stress on the nerve cells bodies to nourish the new fibers
Overused nerve cells cannot handle the stress resulting in the degeneration of the new fibers and ultimately the nerve cells themselves
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http://www.poliosurvivorsnetwork.org.uk/archive/lincolnshire/library/trojan/pathophysiology.html
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Worldwide statistics :
Polio affects children ≤ 5 years old
Irreversible paralysis: 1 in 200 infections◦ Between 5-10% will die from breathing
complications
99% decrease in cases since 1988◦ As of 2013, only 416 reported cases
◦ Estimated 350,000 cases in 1988
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Worldwide statistics :
As of 2014, only 3 countries remain polio-endemic◦ Afghanistan◦ Nigeria◦ Pakistan
125 countries were polio-endemic in 1988
Global efforts to eradicate polio have resulted in the decreases
Polio was considered eradicated in the USA as of 1979
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There are not exact statistics
About 60% of polio survivors from 1940’s and 1950’s have developed PPS
Study done in 1995 estimated that there are about 1 million polio survivors in the US, with 443,000 people who had paralytic polio
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Incubation of polio virus is 6 to 20 days
Mostly fecal-oral transmission through contaminated food or water
Oral-oral transmission is possible
Persons are infectious as long as the polio virus is present in feces or throat◦ Present in throat 1 week after onset of illness
◦ Present in feces approximately 3-6 weeks
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Risks include:
Patients with severe polio symptoms have a higher chance of developing PPS
Longer recovery time from initial polio infection
Older age at the initial polio infection
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Confirmed history of paralytic polio
o Electromyography (EMG), History,
Physical exam
Partial or fully recovery from the acute Polio episode
At least 15 years of having neurological and functionality stability
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After the stable period, gradual or quick onset of weakness with or without generalized fatigue, muscle atrophy, muscle or joint pain
Persistence of symptoms for at least a year
No other medical explanation for the symptoms
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Symptoms can be mild to moderate ◦ Those with severe symptoms from Polio, may
experience more severe PPS symptoms
Symptoms include: ◦ Cramps
◦ Cold intolerance
◦ Generalized fatigue
◦ Joint degradations
◦ Muscle weakness
◦ Muscle atrophy
◦ Pain
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Overuse of muscle increases weakness especially in:
o Biceps femoris
o Quadriceps muscles
Muscle disuse increases
weakness
Patients experience increased muscle weakness after a period of low physical activity http://lrgoodman.hubpages.com/hub/Muscles-Used-While-
Running#slide3673780
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Shortness of breath◦ Decline in function of respiratory muscles such as
the diaphragm
Dysphagia◦ Difficulty in swallowing can lead to issues with
eating and drinking
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Aspiration pneumonia
Dehydration
Loss of balance may lead to a fall and fracture and potentially broken bones
Malnutrition
Osteoporosis can develop upon:
o Immobility
o Prolonged inactivity
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No effective pharmaceutical treatments has been proven to stop or reverse the effects of Post-Polio Syndrome
Non-pharmaceutical options are currently recommended treatment
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Ineffective◦ Amantadine◦ Coenzyme Q-10◦ Modafinil◦ Prednisone ◦ Pyridostigmine
Possibly beneficial ◦ Intravenous
immunoglobulin (IVIG)◦ Lamotrigine
(Lamictal®)
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Blood product
Antibody protein that can help regulate or boost the immune system
Intramuscular or intravenous administration
Contraindications◦ IgA deficiency, severe allergy to corn (Octagam),
intolerance to fructose
Warnings and Precautions◦ Increased chance of blood clots◦ May be harmful to the kidneys
Side Effects◦ Irritation, headache, upset stomach and bowels
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Oral tablet Works by stabilizing neuronal membranes May improve activity limitations Contraindications◦ Severely allergic to lamotrigine
Warnings and Precautions◦ May cause severe skin reactions, report to doctor
Side Effects◦ Drowsiness, dizziness, headache, insomnia, upset
stomach and bowels, blurred vision, anxiety, double vision, and rhinitis
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Therapy◦ Physical, speech, and occupational
Assistive Devices◦ Braces, crutches, wheelchairs, scooters
Surgery
Breathing Assistance Devices◦ BiPAP: bi-level partial airway pressure
◦ Ventilators
Static Magnetic Fields
Physical exercise
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One study showed a decrease in pain immediately after treatment ◦ Vallbona C, Hazelwood CF, Jurida G. Response of pain to
static magnetic fields in postpolio patients: A double-blind pilot study. Arch Phys Med Rehabil 1997;78:1200-1203.
Study used BIOflex® magnets on painful areas
Muscle strength, endurance, and fatigue were not assessed
No known side effects
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Benefit◦ Patients with regular physical activity have fewer
symptoms and higher level of functioning
Avoid overuse ◦ Counterproductive
◦ Further weakens rather than strengthens muscle groups
Physical Therapist is recommended◦ Customize a routine
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Low to moderate intensity
Slow progression
Rotate exercise types◦ Stretching
◦ Cardiovascular
◦ Strength training
Stop or reduce your regimen if◦ Additional weakness
◦ Excessive fatigue
◦ Prolonged recovery time
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Somatic pain Neuropathic pain
Bone, joint, muscle
Localized, throbbing or sharp pains
“Nerve pain” due to damage of nerves
Shooting, stabbing, prickly
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http://www.interactive-biology.com/wp-content/uploads/2012/09/HumanSkeletonFront-819x1024.jpg
http://modernhealthandfitness.com/wp-content/uploads/2011/12/muscles-anatomy-body1.jpg
http://www.onset.unsw.edu.au/issue7/afp1.gif
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Commonly somatic (muscle, joint, bone) and neuropathic pain
Pain classification in PPS◦ Overuse pain
◦ Biomechanical pain
◦ Bone pain
◦ “True” PPS pain
Combination of muscle, joint, and/or bone pain
◦ Classification according to UCLA neurologist
Dr.Susan Perlman
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No guidelines or specific recommendations for pain management in PPS
Depends on the type of pain experienced by a patient ◦ Case by case, individualized treatment
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“Overuse pain”
No medications to target this type of pain
Overuse pain can be a good thing◦ It helps you have a reference point of when it is
time to cut back on certain physical activity
◦ “Time to take it easy and rest”
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“Biomechanical pain”
Lower back pain, spine, neck, knees, feet, and ankles
Non-steroidal anti-inflammatory drugs (NSAID’s)◦ Ibuprofen, naproxen (both prescription and Over-
the-counter strengths)
Side Effects ◦ Mild, moderate, or severe pain along with
inflammation
◦ Gastrointestinal bleeding, kidney impairment, long term use can affect blood pressure
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“Bone pain”
Includes both bone and joint
Acetaminophen (Tylenol®)◦ Mild to moderate pain
◦ Dosages
325 – 650 mg by mouth every 4 – 6 hours
MAX: 3 grams per day
Liver damage
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“True PPS pain”
Includes muscle, joint, nerve pain
◦ Somatic and neuropathic
Non-narcotic drugs◦ Muscle relaxants
◦ Serotonin stimulating agents
◦ Nerve stabilizers
Opioids
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Muscle relaxants (commonly used products) Cyclobenzaprine (Flexeril®)◦ 5mg three times a day [Max: 30mg/day]
Carisoprodol (Soma®)◦ 250-350mg up to four times a day
Baclofen (Lioresal®)◦ 5mg three times a day [Max: 80mg/day]
Tizanadine (Zanfalex®)◦ 4mg once a day [Max: 36mg/day]
Side effects:Sedation, drowsiness, decreased liver function
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Serotonin-stimulating agents◦ Tramadol (Ultram®)◦ Affects pain perception and response◦ Now a controlled medication (Schedule IV)
Immediate-release: 25-100 mg Q4-6H
MAX: 400 mg/day
Extended-release: 100 – 300 mg Daily
MAX: 300 mg/day
◦ Patients with kidney and liver issues need lower doses
◦ Side Effects Stomach and intestinal issues, possibly seizures
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Nerve stabilizers ◦ Gabapentin (Neurontin®)
Dose: 1800-3600mg/day
◦ Pregablin (Lyrica®) (controlled: Schedule V)
Dose: 150-600mg/day
Both need to be started at a low dose and gradually increased
Side Effects
◦ Sedation, dizziness, weight gain, and dry mouth
Patients with kidney problems need lower doses
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Opioids
Hydrocodone agents◦ Lortab®, Norco®, Vicodin®
Contain hydrocodone/acetaminophen (doses vary per product)
◦ Recently changed to Schedule II More of a challenge to get the prescription and currently
in Las Vegas the supply is not meeting the demand
Morphine ◦ Immediate release and extended release
Oxycodone◦ Very effective for most patients but has potential
for tolerance and abuse
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Marijuana
Currently acceptable for chemo-induced nausea, glaucoma, multiple sclerosis, and neuropathic pain ◦ PPS may be fitting due to neuropathic pain
Legal Issues◦ Must obtain medical marijuana card
◦ Conflicts with dispensaries Depending location or state
◦ Conflict with state and federal laws
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No cure for Polio
Can be prevented through vaccination◦ First polio vaccine was introduced in 1955
Prevention of PPS is through protection against Polio
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www.ei-resource.org/easyblog/enty/vaccinations-in-chronic-fatigue-syndrome-and-fibromyalgia/
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Oral Injectable
Live
Low cost
Easy administration
Can cause wild type infection◦ Rare, 1 case per 2.4
million vaccinated
World Health Organization (WHO) still recommends as vaccine of choice
Inactived Only used in countries
with low risk of exposure and high vaccination coverage
Routinely used in United States, Scandinavia, and The Netherlands
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PPS is a syndrome characterized by muscle weakness and fatigue that only occurs in Polio survivors after a period of at least 15 years of no symptoms
Oral vaccine is still utilized in other areas of the world even though there is a small chance it can cause the wild type infection with the Polio virus
In the USA only the inactive vaccine is used
Many people who get Polio develop PPS later in life
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There are no pharmaceutical options that are proven to work for PPS
It is important to use physical exercise appropriately which is why seeing a Physical Therapist is recommended
Pain associated with PPS can be treated with both over the counter options as well as prescription medications
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Gonzalez H, Olsson T, Borg K. Management of postpolio syndrome. Lancet Neurol. 2010;9: 634-642.
Post-Polio Health International. A Statement about exercise for survivors of polio. Post-polio health. http://www.post-polio.org/edu/pphnews/pph19-2a.html. Accessed February 16, 2015.
IVIG. In: Lexi-Drugs Online. Hudson, OH: Lexi-Comp Inc; October 2014. http://nv-ezproxy.roseman.edu:2075/lco/action/doc/retrieve/docid/patch_f/3023999#f_brand-names. Accessed February 16, 2015.
Lamotrigine. Lexi-Drugs Online. Hudson, OH: Lexi-Comp Inc; December 2014. http://nv-ezproxy.roseman.edu:2075/lco/action/doc/retrieve/docid/patch_f/7141#f_warnings-and-precautions. Accessed February 16, 2015.
National Institute of Neurological Disorders and Stroke. Post-Polio Syndrome Fact Sheet. http://www.ninds.nih.gov/disorders/post-polio/detail_post_polio.htm. Accessed February 17, 2015.
Baumann TJ, et al. Chapter 44: Pain Management. In: Pharmacotherapy: A pathophysiologic approach, 9th ed. 2014
MD Perlman S. Use of Medication in People with Post-Polio Syndrome. Polio Network News Am. 1999;15(1):1-2.
U.S Department of Health and Human Services: National Institute of Health. Post-Polio Syndrome. May 2012. http://www.ninds.nih.gov/disorders/post_polio/Post-polio-syndrome-FSV2.pdf. Accessed February 16, 2015.
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