Can Medical Marijuana Offer Relief For Painful Diabetic Neuropathy?

Noting that pharmaceutical interventions for neuropathy can have side effects, researchers are beginning a study on the effects of cannabis to treat neuropathic pain in patients with diabetic peripheral neuropathy.

Lead researcher Stephen Barrett, DPM, FACFAS, believes there is an indication for cannabis when conventional therapies such as gabapentin (Neurontin, Pfizer) or pregabalin (Lyrica, Pfizer) do not provide any substantive relief of the patient’s neuropathic pain.

“There are patients who want something natural but there is a huge stigma for many patients with very severe symptoms who need to be educated about the properties of the medical marijuana, and that ameliorates much of the perception,” says Dr. Barrett, an Adjunct Professor within the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences. “However, in my experience, these patients are so miserable that they will try anything. We like to recommend other methods of administration such as sublingual drops and lozenges, rather than smoking.”  

In certain patients, Stephanie Wu, DPM, MSc, feels cannabis may be an effective treatment for symptomatic neuropathy. However, she notes that based on current literature in this area, cannabis is not an end-all, be-all product to alleviate symptomatic neuropathy in every patient. Although a certain portion of the population will be drawn to cannabis because it is a natural substance, Dr. Wu feels that for most people, the level of pain and discomfort will be the bigger driving force for trying cannabis rather than it being a natural substance.

When considering the use of cannabis for symptomatic neuropathy, she advises considering the associated psychotropic and undesired central nervous system effects such as dependence and tolerance. Cannabis may not be well suited for patients with a history of substance abuse or serious psychiatric disorder that might be exacerbated by medicinal cannabis, cautions Dr. Wu, the Associate Dean of Research and a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University.

Dr. Barrett notes medical marijuana is contraindicated in pregnant women as tetrahydrocannabinol (THC), a chemical in marijuana, can pass through the placental barrier and women excrete it in breast milk. Cannabinoids also affect neuroplasticity in a negative manner in patients under the age of 18, according to Dr. Barrett. Although some argue that medical marijuana would be contraindicated in patients who are on long-term opioid therapy, Dr. Barrett cites research that when patients used medical marijuana in conjunction with opioids, it had a greater cumulative effect in pain reduction and over time, patients were able to reduce the amount of opioids they took.

Additionally, Drs. Wu and Barrett cite a systematic review and meta-analysis of randomized controlled trials, published in the Journal of Pain. that compared inhaled cannabis with placebo in the treatment of chronic painful neuropathy. Assessing 178 participants, researchers found that inhaled cannabis may provide short-term relief for one in five to six patients with neuropathic pain.  

Dr. Barrett notes that because of the legal ramifications of cannabis use in states where medical marijuana is not legal, there is formidable pushback to keep cannabis from passing referendums. However, he believes that will change in the future as more and more states legalize medical marijuana.

For more info on the study, visit www.indiegogo.com/projects/medical-marijuana-for-neuropathy-study#/ .

Study: Cheilectomy Is An Effective Alternative To Arthrodesis For Hallux Rigidus

By Brian McCurdy, Managing Editor

A recent retrospective study in the Journal of Foot and Ankle Surgery says aggressive cheilectomy can be effective for hallux rigidus.

The study focused on 58 patients and had a mean follow-up period of 7.14 years. Authors note the mean percentage of success with this operation was 87.69 percent, adding that 51 of 58 patients experienced no limitations in their daily activities. The study researchers say cheilectomy is an alternative to the joint destructive procedure of first metatarsophalangeal joint (MPJ) arthrodesis.

“Cheilectomy is a great surgery,” says Bradly Bussewitz, DPM, who is in private practice at Steindler Orthopedic Clinic in Iowa City, Iowa. As he explains, cheilectomy has a low complication profile, is technically easy and provides solid pain relief. He tells patients cheilectomy “does not burn any bridges” and he can always fuse the joint if necessary. According to the study, two patients had a subsequent arthrodesis after having a cheilectomy.

In comparison with arthrodesis, cheilectomy offers quicker recovery and has less risk for morbidity, according to Dr. Bussewitz. One advantage of performing the cheilectomy over the arthrodesis is preserving joint motion, according to study lead author Nicole Nicolosi, DPM, a member of the orthopedic staff at Cleveland Clinic in Cleveland. She notes that disadvantages are recurrence/progression of degenerative joint disease and pain.

In the short-term and midterm, Dr. Bussewitz has found “very pleasing” results for his patients with cheilectomy for hallux valgus. He notes that research has shown limited longer-term complications for cheilectomy.

Does Type 1 Diabetes Put Patients At Higher Fracture Risk?

By Brian McCurdy, Managing Editor

A recent study in Diabetes Care notes that patients with type 1 diabetes experience more fractures, particularly in the lower extremity, beginning in childhood and stretching across a lifetime.  

The study compared 30,394 participants with type 1 diabetes with 303,872 participants without diabetes. The authors note lower extremity fractures made up a higher proportion of incident fractures in people with type 1 diabetes versus those without diabetes, citing 31.1 versus 25.1 percent in men and 39.3 versus 32 percent in women.

Jennifer Pappalardo, DPM, notes that one of the least understood complications of type 1 diabetes is the effect on the skeletal system of pediatric patients. She cites studies establishing an increased risk of fracture for those with both type 1 and type 2 diabetes, and adds that those with type 1 have a greater risk. As Dr. Pappalardo notes, males had the highest fracture incidence at an age of 10 to 20 years as opposed to females who had the greatest fracture incidence at 80 to 90 years of age. This increased fracture risk often coincides with a decreased bone mineral density reported in 50 percent of patients with type 1 diabetes.

“Since type 1 diabetes is usually diagnosed during adolescence, the predisposition for reduced bone strength at a younger age can set the stage for pathologic fractures later in life,” says Dr. Pappalardo, an Assistant Professor at the University of Arizona College of Medicine.

Edwin Harris, DPM, FACFAS, has a small type 1 diabetes patient population, who mostly have the same issues as non-diabetic children. However, he does see many pediatric fractures “and I can say with conviction that type 1 diabetes does not make this group predisposed to fracture.”

Dr. Pappalardo notes increasing bone mineral density may serve as protective barrier from fracture occurrence. She suggests that a routine exercise program of weightbearing sports/activities will optimize bone mineral density acquisition during child growth and notes that studies have suggested the importance of adequate vitamin D and calcium intake in those with diabetes.

Dr. Harris also notes a “huge rise” in recognizing vitamin D deficiency in those with type 1 diabetes. He adds that vitamin D deficiency does lead to rebound hyperparathyroidism and could predispose patients to fracture. In regard to addressing vitamin D deficiency, physicians can help educate patients on increasing Vitamin D to therapeutic levels, increasing calcium or engaging in low fracture risk physical activities to maintain bone mass, according to Dr. Harris, a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill.

Complications of pediatric hip fractures can include limb length discrepancies, acetabular growth disturbance and dysplasia, joint incongruity, osteonecrosis, and nerve sciatic, femoral and lumbosacral nerve deficits, notes Dr. Pappalardo. She says these complications can manifest later in life and compound the effects of impaired proprioception, balance and gait.