EFTA01114703.pdf

Jnging the Face of Pain Management 12 Complementary and Alternative Medicine 19 Practical Aspects in Pelvic Pain Treatrr t You Eat: Managing Chronic Pain 14 Treating Post-deployment Chronic Pain 20 Talk on Analgesia Explores New Appraoches to Pain Management ossification and Treatments: Master Class 18 Chronic Pain Problems Among the Medically Underserved 22 Taking a Better Look at Drug Interad in Challenging Populations RECAP Ig the Concept of the Integrated Research into the Intl linic Means Demonstrating Verifiable of Music and Neuroi Icy tion May Unlock Nel rry approach to pain management produces the best outcomes for patients. Clinicians who Treatments this approach must avoid repeating the mistakes of the past and concentrate on providing New data is demonstrating the heali service. of music and suggesting new applica management Schatrnan. "This strategy works because interdisciplinary pain Discrepant Goals in Pain management really does help nearly all stakeholders. The trick is int: Strategies for Balancing learning to demonstrate that: S tny everal presentations during PAINWeek rsician, and Other To ilustrate the challenges pain specialists face, Schatrnan will the ways in which the brain interacts 1 r Needs" (SIS-19) start by tracing the sad decline of interdisciplinary pain manage- , pail. On Tuesday, Michael B. Elko. ment and explaining why a nation that had more than 1,000 Daniel F. Cleary presented on the ways ii Ali ice' E. Schatman, PhD, CPE, DASPE integrated drics in 1998 has fewer than 100 today. can help to aleviate pero. OnWednesday, Reb Integrated pain management clinics initially opened, both spoke about how our brains can be positively y, September 8 inside hospitals and independently, because researchers consis- pail differently. The trend contrwed Friday n 1- 12:10pm tently found that coordinated teams of complementary pain spe- tin by Maio J. Trans, MD, PhD, Director Insi al 4, Mont-Royal Ballroom cialists—usually a physician, a psychologist, a physical therapist, a Brain Science; Department of Neurology, Dc nurse practitioner, and possibly several others—provide the best of Medicine at UCLA. Fis presentation, 'The care for serious chronic pain. Nesomodulation of Pain Responses," provided rdisciplinary pain dinics are an endangered Indeed, the research looked so good that insurers became (by how the human brain processes sound.VVhileT patient numbers keep dwindling, and their their standards) positively enthusiastic about pain clinics, many adze in the management of pain, he has pa Ming, all because financial considerations of- of which responded to the easy money by adding services and studies that have examined the correlation b elfare. padding bills. Worse, the flow of insurance money inspired under- that way it inpads our bodies. ernment would compel hospitals to main- qualified (and occasionally dodgy) practitioners to open their Tramo began by telling the audience tha: rce insurers to cover treatment, says Mi- own clinics to make a quick buck. sic as a healing power dates bock thousand! 1, PhD, CPE, DASPE, Executive Director of Costs rose. Outcomes worsened. Insurers began slashing mythology, Apollo was associated with both r Ethics in Pain Care. Until such mandates reimbursement rates and dropping coverage altogether. Clin- Asclepius, a Greek god of healing, was belie. help rid sick patients of their disease. While tl cal figures, the fact is that there have been rs to see things from the other anecdotal reports over the centuries about tio ameliorate pain and suffering across a wide rspective and show how he benefits eases, and clinical settings. Yes, it is important when dealing with any kind of anecdotal dc or desired course of action. This some of these recounted experiences have I- study of the correlation of music and healing works because interdisciplinary There is also a growing body of evidence nagement really does help nearly ized-controlled trials demonstrating music's of agement, said Tramo. He went on to discus holders. The trick is learning to ing the pathways by which the brain proces that, basically, our brains have an auditory N rate that. (con over, Schatman has some advice for cli- ics began losing money. Then many of them shut their doors. Experience the expanded Living Bey to revive the integrated pain program, Needlessly, according to Schatman. a "multimedia showcase that presen ore today at PAINWeek 2012 during his "Patients suffered because everyone got greedy," Schatman EFTA01114703 r rain management in America )ents touch on all aspects of the delivery of quality pain care—from the research laboratory to the exam room, from the courtroom ambers across the nation. are starting to worry about prescription drug abuse. He says to spot opioid abuse (or even potential abu that "Pain specialists may think they can't possibly hear any patients overcome any problems that develc ents in Law and Public more about the dangers of opioid abuse, but they haven't selors strike many as a natural fit for pain ilia ications for Pain Care heard anything yet. The issue has finally reached a tipping few insurers cover addiction treatment, whi 3" (SIS-20) point in terms of mainstream media coverage, which means a non-starter, until the Affordable Care Ac coverage will perpetuate itself, probably until the problem is law mandates coverage for addiction treatn mei C. Barnes, JD 'solved" in the public mind. Barnes notes that in the past year or financially feasible opportunities for pain p two, "nearly every major newspaper in America has published to serve patients better (and, potentially, r y, September 8 articles highlighting the fact that prescription opioid overdoses ity), either by hiring their own counselors or I 20pm kill more people each year than car crashes in some states," third-party treatment programs. ≥I 4, Mont-Royal Ballroom along with other now-familiar factoids about the effects of pre- "Most of the people in the audience prob scription opioid abuse and misuse. In the wake of these news to like hearing most of what I have to say," Bc reports, celebrity overdoses continuing to make headlines, and is different. This is a real opportunity for care nth isn't the only thing that will change how sensational media accounts of "addicted babies: Barnes says The greater legal risks faced by dinicians ciafists treat patients in the upcoming year. that "we've already seen an uptick in opioid-related legislation, oids "too freely" is another trend that should •ange of recent legal, financial, and cultural regulation, litigation, and prosecution. And more is coming. attendees, says Barnes. Criminal prosecutions an more to affect standards of care. Probably a lot more: mills and "careless" practitioners are on the nes, JD, managing partner of DCBA Law Another important trend is that pain advocacy groups are California stood trial for second-degree murd Igton, will outline the most relevant recent losing funding and power. Barnes says that concerns about patients overdosed. The local DA argued that n what they could mean for pain clinicians the opioid abuse problem were already deterring donors, even ment that there was nothing she could do tc in his presentation this evening, "Current before this year's public relations nightmare in which investiga- from taking a month's worth of pills in one da d Public Policy: Implications for Pain Care tions shined a spotlight on the close ties between some phar- ful omission, and thus justified the murder chc maceutical companies and advocacy groups. Oddly, these in- Civil suits are dso on the rise, both against dc legislators, regulators, and journalists have vestigations come just as drug makers—worried that efforts to companies. In one case, a family landed survh terested in pain management recently, and curtail opioid abuse will slash overall sales and profits—are cut- workers compensation policy after their relative iuch in the past year to exercise their power ting expenditures on pain advocacy. Pain advocacy groups are opioids for an on-the-job story overdosed. Insu is and their patients. thus losing money from all sides at the very moment when their ginreig to increase restrictions on coverage of c According to Barnes, tamper-resistant op make-or-break moment. This is an issue becc Pain specialists may think they can't studies suggest that new formulations do inc often quite dramatically—financial considerati possibly hear any more about the dangers from the market unless the government mand become tamper resistant. Today's tamper re of opioid abuse, but they haven't heard are more expensive, branded products. Man anything yet. The issue has finally reached pay for them, and most generic drug maker licensing fees to make their products tamper t a tipping point in terms of mainstream Finally, Barnes says that clinicians who pn soon need extra training courses. A couple media coverage. ready mandated new educational prograrr prescribes controlled substances. Many oche potentially influential events is huge: hun- message about the importance of treating pain is falling out ering it, as is the US Congress. •ds each year, certainly: says Barnes. "The of favor. As a consequence, Barnes warns that pain specialists "The first trend — growing public concern sense of them is to look for trends, and I've and advocates could see their ability to influence legislatures, drug abuse — underlies all the others," Barnes nes that people who treat pain really should insurers, and the public decline. bly drive more changes to the industry than a inderstand: Addiction treatment may become a major component of iccording to Barnes, is that more Americans pain care. Because their expertise would, in theory, allow them ued from cover) observe the effects in a controlled environment. Although it was a 4 respond to or get excited by sound. Based small-scale study (seven control babies, seven test babies), Tramo terprets these sounds, our body gives a natural said it prodcued some interesting results. The music "created a lot had the experience of going to the dentist and of stabiTrty and lowered the blood pressure of those infants that it g 11our teeth. How many of us have grabbed was played for: Although only two of the four babies who had clenched our hands to try and decrease the not heard the music stopped crying following the heel stidc, all four rt we are having in our mouths? Any of us who infants who hod been able to hear the music stopped crying. evoking the gate theory for pain. We are alo- Tramo told the audience to keep an eye on a relatively new journal EFTA01114704 UPIWeek: e to the fourth and final day of the conference. medication facts." Roger B. Fillingim, PhD, will discuss sex and hedule today features the four sessions of this Complementary and Alternative Medicine gender differences in pain management and explore possible answers to the question "Do we need pink and blue pills?" Today's Schedule of presentation that focus on pain medicine nurs- Cam-Ann Gibson, MD, and Ilene R. Robeck, MD, will exam- Recommended Cou resented by pain management experts from the ine key topics and challenges in evaluating and treating chronic *ion, the second half of the pharmacotherapy pain in veterans following deployment. for First-time PAINVI lule also includes a trio of sessions on regional Following the morning break, at 11:10am, Lora McGuire, cluing pelvic pain, arm and hand pain, and MS, RN, will explore topics in the management of postoperative Attendees ("phantom tooth pain"). The Special Interest pain, induding preemptive analgesia, special methods of delivery cover topics in pharmacy-based pain services, of pain control, and nonopioid, opioid, and adjuvant analgesics. ferences in pain management, new develop- Srinivas Nalamachu, MD, will discuss the clinical characteris- 7:OOam-8:OOam Kiblic policy, and the influence of various pain tics, assessment diagnosis, and treatment of arm aid hand pain. ',alders on the physician-patient relationship. Michael E. Schatrrtan, PhD, will talk about the evolving Nutrition and Pain: Simple R it 7:00am with Hal S. Blatman, MD, present- influence of non-patient and non-physician stakeholders in pain for Pain-Free Health thition aid pain that will explain the ways in management (insurance, hospital, pharmaceutical, implantable s in our patients' diets actually stop their bod- device, and urine drug testing industries, etc) and explain why Hal S. Blatman, MD nd get in the way of rehabilitation? Blatman these various actors must coalesce into a "mutually cooperative ecific nutrients that will augment healing and/ system' if the suffering of pain patients is to be ameliorated. 7:OOam-8:OOam luce pain? Debra J. Drew, MS, ACNS-BC, At 12:30pm, the schedule features the final two satellite events ie the challenges associated with pain assess- of PAINWeek 2012. The faculty of "Persistent and Breakthrough Pelvic Pain care setting, especially in special populations. Pain: Responsible Opioid Prescribing for Multidimensional Colleen M. Fitzgerald, MD sr, Phenyl!), BCPS, will give a talk on phar- Disorders" will consolidate clinically relevant scientific studies and pharmacokinetic evidence-based guidelines pain and paVia- into practical approaches to 8:10am-9:10am M. Fitzgerald, persistent pain and break- e epidemiology through pain assessment, Analgesia: What are the Op le chronic pelvic responsible opioid prescrib- Helen N. Turner, DNP, RN-BC, PCN s in pathophysi- ing, and repeated re-eval- diagnosis, and uation of patient outcomes. s and treatment "Mission: Pain Management 9:20am-10:20am irome. - The Efficient First Visit (An Speed Dating with Pharmaci ert A. Bonak- IDEAL® Clinical Encounter)" iew the preva- v/il discuss nociceptive, neu- 50 Top Medication Tips at Er nd most con- ropathic, and centrally-me- Mary Lynn McPherson, PharmD, BC 'pies as well as diated chronic pain; the risks ne patient con- and benefits of nonpharma- Kathryn A. Walker, PharmD, BCPS complementary cologic and pharmacologic spies in pain management. Helen N. Turner, treatments for chronic pain; barriers to the optimal use of opioid 11:10am-12:10pm 4S-BC, on the use of multimodal analgesia in analgesics in chronic pain; and methods for screening and risk miti- She will also cover various nonpharmaceuticol gation in the initial and follow-up care of patients with chronic pain. Pre- and Postop Pain Manag to be effective additions to multimodal pain At 2:10pm, Hal S. Blatman, MD, will present "a wide range of Lora McGuire, MS, RN McPherson, Phenyl!), BCPS, will elucidate options for treatment, recovery, and body maintenance fa a healthy cokinetic and phormacodynamic properties of aid pain-free life" for women at midge. Bill Paquin, CEO ofVertical mysterious methadone," covering a range of Health, will explore "the pivotal role that Web aid mobile applications 2:10pm-3:10pm propriate titration strategies as well as how to wi ploy to both increase the efficiency of physician practices and inverted from another drug to methadone? improve patient outcomes" in pain management. Edward S. Lee, Women on the Verge: Sleep, first of three satellite programs scheduled for MD, and Tu A. Ngo, PhD, MPH, will offer a plenary session focus- and Pain at Midlife 'atients and Your Practice: The Role of Drug ing on managing psychiatric comorbidties in chronic pain. Gary W. Hal S. Blatman, MD pin and Risk Management," sponsored by Alere Jay, MD, will present a master class on the differential diagnosis and hire Jennifer E. Bolen, JD, and Jeffery A. management of migrare and tension-type headache. issing practical approaches to incorporating Following the afternoon break, Carol P. Curtiss, MSN, 5:20pm-6:20pm comprehensive chronic pain and risk manage- RN-BC, will discuss key principles involved in balancing effective pain management and saeening for risk of substance misuse and VA Health Care: This is Not theft A. Bonakdar, MD, continues the addiction in persons with pain. Peter A. Foreman, DDS, will Your Father's VA id Alternative Medicine track with "Overview examine the difficult diagnostic and treatment challenges Lucile Burgo-Black, MD, and Stephi Dietary Supplements," during which he will associated with orofacial neuropathies. Mary Lynn McPherson, ace of supplement use in specific pain condi- PharmD, and Kathryn A. Walker, PharmD, will duke it out as MD, MPH EFTA01114705 rTeCT In leOTIenTS IGKIng Up10105 nor 'WV is Pain wescribe opioids should be aware of the symptoms of opioid-induced constipation PAINWeek Administ of the pharmacologic options for managing this condition Redza Ibrahim Advertising, Sponsorships, Satellite Events goid-kiduced Constipation: Considerations to of the most common adverse side effects associated with chronic 'propriate Early Targeted Therapy for Better Pa- opioid therapy,' Rhiner said that most patients with chronic pain Darryl Fossa Art Oiled on and Graphic Design ernes," a CME-accredited session yesterday at will experience OIC to some degree. In fact, OIC is reported in at focused on opioid-induced constipation, its up to 90% of patients with cancer pain and 80% of patients with Steve Porada Corporate Relations and the pharmacologic options that are co- chronic nonmalignant pain. She noted that because chronic pain rrect this condition, presenters Bil McCarberg, patients rarely develop a tolerance to OIC, most of them will re- Debra Weiner Course Development O; and Michelle Rhiner, RN-BC, MSN, provided quire some form of pharmacologic therapy for constipation (up motion that clinicians can apply to daily practice. to 94% of patients with advanced illness who take opioids need Holly Caster Editorial Services e session by talking about the scope of the laxatives, the most commonly used therapy for OIC). induced constipation (OIC). Because prescrip- Untreated or undertreated OIC can compromise pain manage- Michael Shaffer Exhibit Sales', Management most commonly used medications in the pain ment in patients with cancer. Rhiner said that surveys have shown alGative care settings, and because OIC is one that O1C can cause patients to switch to switch to a different opioid, Wanda Tarnoff Finance reduce their opioid dose (either in conjunction with their health care provider, or on their own without telling their provider), or even stop Keith Dempster Mock Relations taking opioids altogether. Patients with OIC also use more health coy resources (they have more hospital admissions and doctor visits, Benjamin R. Metzger, MD Meckal Direction use more home health services, etc). Rhiner said that OK also has a negative impact on quality of life and functionality in patients with Jeffrey Tamoff Operations and Technology chronic noncancer pain, leading to missed work, reduced productiv- ity, and compromised mental and physical health. Charles Brown Program Management Rhiner concluded her portion of the session by briefly review- ing normal colorectal functional processes. She said that bowel Patrick Kelly function is "governed by the enteric brain, an organ comprised of Web and Print Production billions of neurons," and that any disruption in the neurotransmit- ter and mechanisms that regulate bowel function (such as those produce by opioids) can lead to constipation and bowel dysfunc- Pain Management tion. She said that OK results when opioids bind with periphery sensors in the gut and in the enteric system.This affects not only the Jack Lapping vke President, Sales colon, but other components of the boweVgastrointestinal system, producing a spectrum of opioid-induced bowel dysfunction. This Steve Porcelli Director of Sales can indude cramping, bloating, decreased appetite, nausea and other symptoms in addition to constipation. She said that many of Cowie Payson Notional Accounts Manager these symptoms are often missed by patients and providers and not attributed to the patient's opioid therapy. Megan O'Connell Soles & Marketing Coordinator Assessing patients for OIC and selecting an appropriate Todd Kunkler Editor management option During his portion of the presentation, McCarberg discussed the Silas Inman Web Editor ients with chronic assessment and management of OK. He said that "there we no good diagnostic criteria for OIC." Although many patients and cli- Stephanie Ogozaly Assistant Web Ecitor experience OIC to nicians focus on stool frequency when discussing O1C, McCarberg said that this might not provide a complete picture because "there John Salesi gree. In fact, OIC is wide variabMty in stool frequency" from patient to patient. Thus, Art Director when assessing patients for O1C, clinicians should also focus on John Burke ed in up to 90% other factors, such as those outlined in the Rome III criteria for Group Director. Ciro,'otion & Production functional constipation. McCarberg reminded the audience that its with cancer these are not necessarily for O1C, just for functional constipation. There are no OIC-specific criteria: MJH & Associates I 80% of patients When assessing patients for O1C, taking a history is important Mike Hennessy to find out the patient's normal boweVdefecation routine in order Choir man /Chief Executive Officer/President mic nonmalignant to establish a baseline. "You have to ask the right questions" about Tighe Blazier Chief Operating Officer :cause chronic pain the patient's previous and current bowel pattern and activity level, their amount of daly fiber and fluid intake, and laxative use prior Neil Glasser, CPA/CFE EFTA01114706  The Rx Guardian itoring gives you the (normalized drug with other clinica indicate that if yo IGHTof Rx Guardian CDs" pain patient falls: • Within -2.0 to higher likeliho you to compare your patient to a database nts clinically assessed for adherence. 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Together with your expertise, Rx Guardian CDS with the Rx GI Report can help you make clinical decisions to enhance the care of your chronic pain Booth #114, to learn more about Rx Guardii EFTA01114707 Kiln-fighting diet that calls for eliminating trans fats, artificial sweeteners, nutritionally deficient foods, digestive tract disruptors, and oth dients, patients may be able to effectively reduce the severity of their pain without the use of prescription medications. hypothesize from what I've read about the mechanisms by Patients must also be willing to wait long p which particular compounds increase pain. But case after case start to see any benefits. Blatman cautions and Pain: Simple Rules for demonstrates a major impact. It's common for my patients with foods take weeks to work their way entirely lealth" (CAM-Ol) fibromyalgia to report that pain goes down by as much as half Others take as long as four months, and a when they eliminate all artificial sweeteners," Blatman says. bite of the wrong thing can set the clock bac S. Blatman, MD, DAAPM, ABIHM The insufficiently nutritious category includes many of the can see significant benefits just by cutting be y, September 8 usual suspects: sugar, potatoes, fruit juices, and many other ingredients I advise against, but in most case foods with high glycemic indexes. only come from total abstinence: Blatman sr )0am As for the digestive tract disruptors, the list there includes Many patients, obviously, will sabotage th. '13, Castellano 1 excessive red meat and all wheat products. "The gut plays an ing here and there. Many end up simply at incredibly important role in good health," Blatman says. "The altogether. good flora that are inside of it break down your food so you "Patients obviously have the right to cho can absorb nutrients properly. They also keep your immune sys- but I make it clear to them that they are doir e owes much of its success to a quality that's tem working right which is why patients with autoimmune dis- ing to be in pain. I also make it clear to the I among foodstuffs: an utter inability to sup- eases get particular relief when they start eating a gut-healthy changes come before any unusually large )st forms of life. diet." Blatman says. ) eat it. Mold takes no root inside it. Even Blatman's dietary recommendations are simple. Sticking to "If they follow the diet religiously and the e it a miss. Industrial food makers, who have them, however, can be tricky. Many diets advise patients to cut try what I can to fix that. But if the pain isn't e a mirade ingredient that can cut costs and back on certain foods and ingredients. Blatman tells patients to a patient to eat better, then it certainly isn't k )ave made it one of the most common ingre- avoid them completely, a maxim that requires not only iron self- to risk his or her health by increasing the op discipline but also frequent detective work. Many of the forbid- and again," Blatman says. "This diet isn't an e humans den ingredients are found in a wide variety of foods, and often anything, but it produces very impressive res ,ond all turn up in unexpected places. Blatman remembers one patient and it can do the same for yours." pds" that who "gave up" wheat but saw no health benefits--because she says Hal had no idea about the wheat in her favorite soy sauce. DAAPM, argarine yedients make us will ex- "Eliminate problem foods and ingredients and youi hINWeek wesenta- patients will hurt less. They'll also respond better tc nd Pain: medications—and develop less tolerance—so you cal 'ain-Free prescribe lower doses and stop worrying about the actively Others kicking down your door." I stop our what they are designed to do: heal them- prevent medications from working properly: ) runs the Blatman Pain Clinic in Cincinnati. rods and your patients will hurt less. They'll er to opioid medications—and develop less :an prescribe lower doses and stop worrying sing down your door." :nt the past couple of decades testing ingre- fighting diet he will outline during his talk. He very credible book and study he can find on le conducts tiny experiments, first on himself, I friends, and finally on patients. of testing have left him with a reasonably elines that seem to provide at least some every patient who sticks to them for any tman says that he cannot scientifically prove mess because he recommends it to every in maintaining control groups, but he be- EFTA01114708 fective 24-hour pain control' nce-daily oral dosing with e evening meal' )w incidence of dizziness V. id somnolence' 14311-Hil+)+0 :ration to an 1800 mg dose - •, 2 weeks' was a reported incidence of dizziness ) vs 2.2% placebo) and somnolence vs 2.7% placebo) at 1800 mg once daily? Watch how GRALI: nore information, r rin technology works 3e visit Booth 316. z Scan the barcode to view the video at ition and Usage ISE' is indicated for the management of Drpetic neuralgia (PHN). GRALISE is not )angeable with other gabapentin products Ise of differing pharmacokinetic profiles fect the frequency of administration. -tant Safety Information ISE is contraindicated in patients who have nstrated hypersensitivity to the drug or its ingredients. ileptic drugs (AEDs) including gabapentin, the active ingredient in GRALISE, increase suicidal thoughts or behavior in patients taking these drugs for any indication. Patient: with any AED for any indication should be monitored for the emergence or worsenir )ression, suicidal thoughts or behavior, and/or any unusual changes in mood or beha% lost common adverse reaction to GRALISE (5% and twice placebo) is dizziness. 3 all GRALISE clinical trials the other most common adverse reactions (2%) are Dlence, headache, peripheral edema, diarrhea, dry mouth, and nasopharyngitis. 'pes and incidence of adverse events were similar across age groups except for leral edema, which tended to increase in incidence with age. ;ee next page for Brief Summary of Prescribing Information, /0-1 • EFTA01114709 antuntunata tiacnue natast tat um %ea...maw at um picouniscin. Dizziness 10.9 2.2 Dose should be adjusted in patents with reduced renal function. GRALISE should not be Somnolence 4.5 2.7 h Gra less than 30 or in patents on hernodialysis. Headache 4.2 4.1 emetic neuralgia. GRALISE therapy should be initiated and nitrated as follows: Lethargy 1.1 0.3 ommended Titration Schedule In addition to the adverse reactions reported in Table 4 above, the followng adverse reactionswith Day 2 Days 3-6 Days 7-10 Days 11-14 Day 15 relationship to GRALISE were reported during the clinical development for the treatment of posthr 600 mg 900 mg 1200 mg 1500 mg 1800 mg Events in we than 1% of patients but equally or more frequently in the GRALISE-treated patient the placebo group included blood pressure increase, confusional state, gastroenteritis viral. herp S hypertension, joint swelling, memory impairment. nausea, pneumonia, pyrexia, rash, seasonal all ated in patients with demonstrated hypersensitivity to the drug or its ingredients. respiratory infection. Postmarlceting and Other Experience with other Formulations of Ga addition to the adverse experiences reported during clinical testing of gabapentin, the following ad age Based on Renal Function have been reported n patients receiving other formulator's of marketed gabapentin. These adverse Once-daily dosing not been fisted above and data are insufficient to support an estimate of their incidence or to establ fistng is alphabetized: angioedema, blood glucose fluctuation, breast hypertrophy, erythema multi( GRALISE dose (once daly with evening meal)