What topical pain relief creams can be ordered through hospice care?

Topical Pain Relief Creams Available Through Hospice

For hospice patients requiring topical pain relief similar to Aspercreme, lidocaine patches (4-5%) should be the first-line choice, followed by topical NSAIDs (diclofenac gel), capsaicin cream, or compounded amitriptyline-ketamine preparations. 1, 2

First-Line Topical Agents

Lidocaine Patches and Preparations

• Lidocaine patches (4-5%) are the preferred first-line topical treatment for localized pain in hospice patients, providing effective analgesia with minimal systemic absorption 1, 2
• Available in over-the-counter 4% concentration or prescription 5% strength, with patches delivering medication gradually over 12-24 hours 1
• Up to 3 patches may be applied simultaneously for broader coverage, and patches can be cut to fit specific body areas 1, 2
• Particularly effective for neuropathic pain, postherpetic neuralgia, and cancer-related pain 1
• Lidocaine cream or ointment formulations are also available, though patches tend to be more effective due to sustained delivery 1

Topical NSAIDs

• Diclofenac gel or patches are recommended for inflammatory pain, offering similar pain relief to oral NSAIDs with a superior safety profile 2
• Topical NSAIDs provide localized pain relief without the gastrointestinal and renal toxicity risks associated with systemic NSAIDs 1
• Can be used as an alternative to opioids for discrete procedures or ongoing localized pain 1

Second-Line Topical Options

Capsaicin Cream

• Capsaicin cream (0.025-0.075%) can be applied 3-4 times daily for neuropathic and localized pain syndromes 1, 2
• Works through desensitization of pain receptors, though patients should be warned about initial burning sensation that typically subsides with continued use 1, 2
• Should be tried for at least 4 weeks to assess efficacy before switching treatments 1

Compounded Amitriptyline-Ketamine

• Topical amitriptyline 1-2% combined with ketamine 0.5-5% applied up to 3 times daily showed improvement in 75% of patients with various pain syndromes 1, 2
• Requires preparation by a compounding pharmacy, with ketamine concentration adjustable up to 5% if initial formulation is ineffective 1
• Blocks sodium channels and N-methyl-D-aspartate receptors to interrupt pain signaling 1

Other Topical Agents

• Menthol-based preparations (similar to Aspercreme's mechanism) may be considered for regional pain syndromes 1
• Topical midodrine 0.2%, phenylephrine, or other vasoconstrictor preparations are available for specific conditions like erythromelalgia 1

Clinical Application in Hospice Setting

Treatment Algorithm

1. Start with lidocaine patches (4-5%) or diclofenac gel for most patients with localized pain 2
2. Add or switch to capsaicin or compounded amitriptyline-ketamine if inadequate relief after 2-4 weeks 2
3. Consider combination therapy with systemic medications if topical agents alone are insufficient 2
4. Trial each topical medication for at least 4 weeks before determining efficacy 1

Important Considerations for Hospice Prescribing

• Hospice patients receiving topical analgesics showed better pain management outcomes compared to those without hospice enrollment 3
• Local therapies including medicated creams, ointments, and patches are specifically recommended for myalgias, arthralgias, neuropathic and myofascial pain in cancer survivors and palliative patients 1
• When multiple body areas are affected, systemic treatments may be more practical than topical options 2
• Off-label topical analgesics may be considered when FDA-approved treatments prove inadequate for individual hospice patients 4

Pitfalls to Avoid

• Do not exceed 3 lidocaine patches simultaneously to prevent systemic toxicity 1
• Avoid using topical NSAID gel for procedural pain management, as evidence is insufficient 1
• Monitor for skin irritation with all topical preparations, particularly with capsaicin which causes initial burning 2
• Ensure continued adherence even as patients become more comfortable, as pain can redevelop if treatment is discontinued prematurely 5