Letters to the Editor: Hormone Dosing, Adhesive Arachnoiditis
Can you please provide the starting dosages of hormone therapy—dihydro-epiandrosterone (DHEA), testosterone (for men and women), cortisol, and progesterone—you typically prescribe? Of course, I would mostly use sublingual troche formulations of the bioidentical hormones, unless you have other suggestions? Please provide some guidance so I can be sure of my outcomes.
Katrina Lewis, MD
Dear Dr. Lewis,
First, I have learned to start hormone replacement at very low levels. The old adage, “start low and go slow” could not be more applicable.
Why? It appears that severe, chronic pain patients have slowly and progressively reduced their hormone reserves and serum levels. In this process, their hormone receptors have down-regulated and will not appropriately react to very high dosages. Consequently, if you initially administer too high a dosage, the patient may develop such ill-effects that they won’t cooperate with treatment (Table 1).
Table 2 outlines my low starting dosages. I raise dosages every 2 to 4 weeks and retest every 1 to 2 months until serum levels are normal.
Special Notes: I only start the hormones listed in Table 2 when I have a low serum level. Thyroid is an exception. I will sometimes start bioidentical thyroid, 1 g/d, with a normal T3 and T4, if there are symptoms of hypothyroidism—such as dry skin, loss of eyebrows, swollen eye lids, fatigue, or hyporeflexia. For reasons I can’t explain, hydrocortisone may not raise serum cortisol levels in some severe, centralized pain patients. I, therefore, use a lot of bioidentical, compounded cortisol. I avoid methylprednisolone, prednisone, and triamcinolone for replacement purposes.
Forest Tennant, MD, DrPH
A Case of Arachnoiditis
I have just finished reading Dr. Tennant’s article on arachnoiditis.1 I would suggest adding spinal anesthesia—especially containing 5% lidocaine and epinephrine—to the list of risk factors. I received such a spinal block for routine knee arthroscopy in 2007. Prior to the procedure, I had no history of back injury, spinal surgery, or spinal concerns. My surgery/anesthesia was administered March 8, 2007. In April 2007, I began to experience nausea, loss of balance, ear pain, and loss of coordination. This progressed to positional headaches, severe stabbing pain in the thoracic spine, arms, and loss of fine motor function in my hands—lumbar symptoms began to develop at that time. My left leg would give out unexpectedly...it felt like it was laying in a bucket of ice water.
In 2010, J. Antonio Aldrete, MD, confirmed that I have spinal adhesive arachnoiditis in the thoracic and lumbar spine (with other associated consequential conditions) as a result of this procedure. None of my clinicians knew that they should have been monitoring me for these symptoms—excruciating pain of unknown origin. At that time, I had 39 of the 52 symptoms of arachnoiditis.
It is truly my hope to prevent future cases of arachnoiditis. Please warn pain management professionals of the risks of lidocaine in spinal anesthesia, as well as the risk of arachnoiditis associated with spinal anesthesia so that other patients can be monitored for these adverse outcomes should they have a spinal block containing this substance.
As exhibited by my Workers’ Compensation Case, which was recently reviewed by the Appellate Division of the New York State Supreme Court; many physicians still use 5% lidocaine for this off label purpose in the belief that it is truly safe to do so. As such, no compensation was awarded for this medical injury. Pain management and treatment protocol for back and knee injury treatment still do not mention any warning about arachnoiditis and still include spinal injections as a part of that protocol.
Sheila L. Kalkbrenner
Wellsville, New York
Your description of arachnoiditis and your own history is most helpful. The incidence of arachnoiditis has risen about 400% in the past decade. Every practitioner who deals with spinal conditions must be aware of the causative factors of arachnoiditis. Those of us who treat pain must continue working to improve the plight of arachnoiditis patients. I will try to relate my efforts on a periodic basis as I continue to observe that my arachnoiditis patients are steadily improving with aggressive analgesia, exercises, glial cell modulators, and neurogenic hormones.
Forest Tennant, MD, DrPH