Naltrexone for Sensory Neuropathic Cough (SNC)

Introduction

Some patients with sensory neuropathic cough have already tried a long list of treatment options, including amitriptyline, gabapentin, duloxetine, venlafaxine, capsaicin spray, triamcinolone injections, and others. They may have experienced little or no benefit, or perhaps meaningful benefit accompanied by unacceptable side effects.

Low-dose naltrexone has shown promise in certain chronic pain conditions, including fibromyalgia. This has prompted us to add it to our list of potential treatments for sensory neuropathic cough, particularly for patients who have exhausted or been unable to tolerate more established options.

What follows is our explanation of this medication, along with instructions for its use.

What Is Naltrexone?

Naltrexone is a medication normally used to treat opioid (narcotic) and alcohol addiction. It is an opioid receptor blocker. Think of a receptor by analogy like a microscopic, cellular “mailbox” dedicated to receiving “narcotic mail.” Naltrexone “goes into the mailbox” so there is no room to put the narcotic in. It keeps the receptors “full.”

When used for the addictions mentioned above, the oral dose is between 50 and 100 mg per day. For SNC, we use between 1.5 mg and 4.5 mg of naltrexone, and only occasionally more. That is less than 5% of the normal dose.

The idea is to fill enough of the “mailboxes” so that the body increases its output of naturally occurring narcotic-like substances called endorphins. 

Who Can’t Use Naltrexone?

Those who are on necessary narcotics like codeine, Tylenol #3, hydrocodone or oxycodone (Norco, etc.), and some cough medications.

You need to be off any such medication for a week before beginning naltrexone.

How do I Take It?

• Week 1: Take one 1.5 mg capsule by mouth in the morning.
• Week 2: Take two 1.5 mg capsules (total of 3 mg) by mouth every morning.
• Week 3: Take three 1.5 mg capsules (total of 4.5 mg) by mouth every morning, and maintain this dose unless directed otherwise by your doctor.

What Are the Side Effects?

We anticipate few if any due to the small dose, but theoretically, things like headache, GI upset, and wild dreams.

Where do I get Naltrexone?

It is not available in the small doses we are using in a standard pharmacy. You must therefore receive the naltrexone by mail from a compounding pharmacy.

What Is the Process?

One of the clinicians you see will create a prescription. This is sent to the compounding pharmacy via fax. Even before (or after) they receive the fax, you can text them your date of birth and name. They will take it from there regarding prepayment and mailing details.

Why do I Have to Pay for This Myself?

The pharmacy may not accept insurance, since insurers pay only for the “medication” and not for the cost of compounding, which would drive this kind of pharmacy out of business.

Furthermore, insurers have no “check boxes” in their databases for this low dose or for a “cough” indication. Cost will be quoted at the time of contact with the pharmacy. Sixty pills are usually enough to establish efficacy (or not).