Iontophoresis is a commonly utilized therapeutic modality in the treatment of both acute and chronic inflammatory musculo-skeletal conditions. Unfortunately, iontophoresis suffers from a lack of evidence to support and expand its clinical use for other conditions. In addition, most practitioners are not familiar with alternate applications for iontophoresis in the treatment of neuropathies, scar tissue, and muscle spasm. This clinical roundtable discussion focuses on advancements in the clinical application of iontophoresis.
Dr. Scifers: What conditions are being treated most commonly and most successfully using iontophoresis?
Dr. Lewandowski: For the most part, superficial inflammatory conditions involving tendons and ligaments. I commonly utilize iontophoresis to treat athletes suffering from acromioclavicular sprains, anterior talofibular ligament sprains, and lateral epicondylitis in an attempt to accelerate their recovery to allow for return to sport.
Dr. O’Brien: Subacute and chronic conditions seem to respond in a more positive manner to iontophoresis. Perhaps this is due to the return of vascular stability and susceptible permeability following acute inflammation. Tendintis, tenosynovitis, and, in some circumstances, musculotendinous junction inflammation respond well to the shallow perfusion of nonsteroidal anti-inflammatory drugs (NSAIDs).
Mr. Watts: For the most part, clinicians seem to be using iontophoresis in the treatment of inflammatory conditions. Some clinicians are utilizing iontophoresis in the treatment of scar formation, muscle spasm, and peripheral neuropathies. As a compounding pharmacist, I have to be careful not to make claims regarding the effectiveness of any medications in the treatment of specific conditions. Any specific drug application requires U.S. Food and Drug Administration approval.
Dr. Scifers: What medications are being used for iontophoresis?
Dr. Lewandowski: I primarily use ketoprofen and dexamethasone to treat inflammatory conditions. Ketoprofen is my first line of attack, followed by dexamethasone. Occasionally, I utilize acetic acid for scar tissue or hematoma formation. Although outcomes using ketoprofen and dexamethasone tend to be consistently positive, acetic acid appears to be less effective in treating musculoskeletal conditions.
Dr. O’Brien: Due to the shallow rate of absorption, many of the common NSAIDs, such as dexamethasone, methylprednisolone, and ketoprofen, have been used to target soft-tissue inflammation. Some pharmacists and physicians have used naproxen sodium in solution with some success.
Mr. Watts: Of all the prescriptions I fill, I would estimate the breakdown as follows: dexamethasone, 75%; ketoprofen, 20%; acetic acid, 3%; gabapentin, 1%; and baclofen, 1%.Clinician use of iontophoresis is much lower than clinician use of other treatment modalities such as therapeutic exercise and manual therapy. I would estimate approximately 25% of clinicians are utilizing iontophoresis in their practice. Of this 25%, I would estimate that 95% of treatments involve the use of dexamethasone. Acetic acid is not supported in decreasing bone spurs. However, acetic acid appears to decrease pain in patients, indicating the possibility of some anti-inflammatory properties. Baclofen is being used to treat muscle cramps and muscle spasms in orthopedic patients and spasticity in neurologically involved patients. Gabapentin, on the other hand, is used in the treatment of neuropathies. Clinicians report that baclofen is effective for short-term relief and in cases of episodic exacerbations. I am not sure of the practicality of long-term use of this medication.
Dr. Scifers: Do you prefer one medication over another in the treatment of inflammatory conditions?
Mr. Watts: As a pharmacist, I find dexamethasone easier to compound. Dexamethasone is soluble in water, whereas ketoprofen is not. Therefore, ketoprofen must be buffered to decrease the risk of patient burns. When compounded at levels closer to skin pH, ketoprofen tends to drop out of solution. Dexamethasone may raise the patient’s glucose levels, so ketoprofen is preferred in diabetic patients or in patients who do not want steroids. In terms of outcomes, there do not appear to be other legitimate reasons to select ketoprofen over dexamethasone.
Dr. Scifers: What trends are you seeing these days related to iontophoresis use in the clinical setting?
Dr. Lewandowski: One advancement in the past decade has been the use of the iontophoresis patch as a replacement for traditional iontophoresis machines. This treatment method allows for low-dose, long-duration medication delivery, resulting in improved treatment outcomes.
Dr. O’Brien: As an industry innovation, the majority of iontophoresis treatment delivery methods are through the self-contained, battery-operated electrodes impregnated with pre-established medications powered through a cased battery. Due to the longer treatment times, a low-voltage battery delivers the medication at a slow rate to bypass the resistance presented by the overlying skin and dermal layer, allowing the patient to wear the patches while continuing their daily activities.
Mr. Watts: Clinicians seem to be practicing what they learned in their entry-level programs. With inconclusive research to guide them, practitioners are sticking with what they know or believe works best clinically. I don’t encounter too many innovative clinicians who are willing to try new things involving iontophoresis. Additional research is needed in the area of iontophoresis.
Dr. Scifers: Are there other medications available that you would encourage clinicians to try using for iontophoresis?
Dr. O’Brien: In instances of desired pain relief, iontophoresis utilizing transdermal analgesics, such as lidocaine and sodium salicylate, might offer clinicians added benefit. Clinicians should always consider their patient’s primary treatment goals when considering any medication administration prior to application.
Mr. Watts: Potassium iodine can be utilized before stretching to assist in breaking up scar tissue. Lidocaine can provide temporary pain relief in superficial tissues. This medication could be more commonly utilized in athletes as a mechanism for providing safe, short-term pain relief. Another potential medication that could be on the horizon in terms of iontophoresis is zinc sulfate. This drug can be utilized as a drying, anti-infective agent in the treatment of dermal conditions.
Dr. Scifers: What treatments are you utilizing instead of iontophoresis?
Dr. Lewandowski: Iontophoresis is not my first line of defense in the treatment of most conditions. I use it most commonly in the treatment of acutely inflamed, superficial tissue that has not responded to other treatments. On the basis of my review of recent therapeutic modalities research, I have begun utilizing phonophoresis more often than iontophoresis for treating acute joint injuries in the lower extremity.
Mr. Watts: Clinicians appear to be increasing their use of transdermal medications that are delivered topically without the use of an electrical current. These treatments commonly involve nonsteroidal drugs, such as ketoprofen. These treatments also allow for multiple medications to be delivered in combination. Many clinicians are utilizing transdermal medications as adjuncts or substitutes to narcotic medications in the treatment of chronic pain patients.
Dr. Scifers: What one piece of advice would you offer clinicians regarding the efficacy and use of iontophoresis?
Dr. Lewandowski: Scant research exists regarding the clinical effectiveness of iontophoresis. What little data do exist generally relate to dexamethasone and ketoprofen. In addition, issues exist surrounding third-party reimbursement for iontophoresis treatment. Clinicians should anticipate seeing results within the first 2 to 3 treatment sessions. In cases where no results are noted within the first few treatments or full recovery is not observed within 6 to 10 treatments, iontophoresis should be discontinued in favor of another treatment modality.
Dr. O’Brien: When reviewing clinical studies evaluating the efficacy of iontophoresis, a clinician must be mindful of the limited depth of penetration that has been reported, along with the limited evidence of dermal penetration through extremely dry and calloused skin. Clinicians should also be aware of the indications for iontophoresis and apply sound clinical decision making regarding transdermal medication delivery.
Mr. Watts: Iontophoresis medications must be specifically compounded for individual patients, as opposed to being prepared for clinics to use in treating multiple patients. Compounding pharmacies are being more closely scrutinized than ever before. These agencies can be accused of distributing medication if prescriptions are not being filled for individual patients. Approximately 15 to 20 states currently have regulations about prescribing only to individual patients. The recent nationwide fungal meningitis outbreak linked to a steroid distributed by a New England pharmacy has increased awareness of the need to better track compounded medications.
This clinical roundtable was conducted February 12, 2013.