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: cmadison@roseman.edu

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

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

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

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®)

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

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/

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.

World Health Organization.Poliomyelitis:key facts. http://www.who.int/mediacentre/factsheets/fs114/en/. Accessed February 20, 2015.

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Centers for Disease Control and Prevention. Interim CDC guidance for travel to and from countries affected by the new polio vaccine requirements. http://wwwnc.cdc.gov/travel/news-announcements/polio-guidance-new-requirements. Accessed February 20, 2015.

Centers for Disease Control and Prevention. Keeping the U.S. polio-free. http://www.cdc.gov/24-7/protectingpeople/polio/us_polio_free.html. Accessed February 20, 2015.

Department of Health. Information for a healthy New York: Poliomyelitis (infantile paralysis, polio). https://www.health.ny.gov/diseases/communicable/poliomyelitis/fact_sheet.htm. Accessed Feb 19, 2015.

Biceps 72.Perry J, Fontaine JD, Mulroy S. Findings in postpoliomyelitis syndrome. J Bone Joint Surg 1995;77A: 1148-1153.

Perlman S. Coping with fatigue of post-polio syndrome. Rancho Los Amigos Post-Polio Support Group Newsletter. February 1999.

World Health Organization. International travel and health:poliomyelitis (Polio). http://www.who.int/ith/vaccines/polio/en/. Accessed February 18, 2015.

Farbu E, Gilhusa NE, Barnes MP et al; EFNS guideline on diagnosis and management of post-polio syndrome: Report of an EFNS task force. Euro J Neuro. 2006;13:795–801.

Trojan D, Cashman NR. Post-poliomyelitis syndrome. Neuro Rehabilitation. 1997;8:83-92.

Mayo Clinic Staff. Post-polio syndrome.http://www.mayoclinic.org/diseases-conditions/post-polio-syndrome/basics/risk-factors/con-20021725. Accessed February 18, 2015.

Farbu E. International Encyclopedia of Rehabilitation. Post-polio Syndrome. http://cirrie.buffalo.edu/encyclopedia/en/article/138/. Accessed February 18,2015.

Kedlaya D. Post-polio syndrome: background. http://emedicine.medscape.com/article/306920-overview. Accessed February 17, 2015.

National Public Radio. Wiping out polio: how the U.S. snuffed out a killer. http://www.npr.org/blogs/health/2012/10/16/162670836/wiping-out-polio-how-the-u-s-snuffed-out-a-killer. Accessed from February 18, 2015.

Ben-Achour S. American University Washington DC. Polio survivor and doctor chooses new path. http://wamu.org/programs/metro_connection/12/11/02/polio_survivor_and_doctor_chooses_new_path. Accessed February 18, 2015.

National Institute of Neurological Disorders and Stroke. Post-Polio Health International. Definitions. http://polioplace.org/living-with-polio/definitions. Accessed February 18, 2015.

Post-polio syndrome fact sheet. http://www.ninds.nih.gov/disorders/post_polio/detail_post_polio.htm?css=print#261673172. Accessed February 18, 2015.

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