General

Pronunciation:
kap-say-sin

Trade Name(s)

• Capzasin-HP
• Capzasin-P
• DiabetAid Pain and Tingling Relief
• Qutenza
• Zostrix
• Zostrix-HP

Ther. Class.

nonopioid analgesics

(topical)

Indications

• Temporary management of pain due to rheumatoid arthritis and osteoarthritis.
• Pain associated with postherpetic neuralgia (topical and transdermal) or diabetic neuropathy.

Unlabeled Use(s):

• Postmastectomy pain syndrome.
• Complex regional pain syndrome.

Action

•  Topical: May deplete and prevent the reaccumulation of a chemical (substance P) responsible for transmitting painful impulses from peripheral sites to the CNS.
•  Transdermal: Initially stimulates the transient receptor potential vanilloid 1 (TRPV1) receptors on nociceptive nerve fibers in the skin; this is followed by pain relief thought to be due to a reduction in TRPV1-expressing nociceptive nerve endings.

Therapeutic Effect(s):

Relief of discomfort associated with painful peripheral syndromes.

Pharmacokinetics

Absorption: Unknown.

Distribution: Unknown.

Metabolism and Excretion: Unknown.

Half-life: Unknown.

TIME/ACTION PROFILE

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity to capsaicin or hot peppers;
• Not for use near eyes or on open or broken skin.

Use Cautiously in:

• OB:   Safety not established in pregnancy;
• Lactation:  Safety not established in breastfeeding;
• Pedi:  Safety not established in children <18 yr (transdermal) or <2 yr (topical).

Adverse Reactions/Side Effects

CV:  Patch: ↑ BP

Derm: application site burns, pain (after application of patch), transient burning

Neuro: ↓ sensory function

Resp: cough

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

None reported.

Route/Dosage

Topical (Adults and Children  ≥2 yr): Apply to affected areas 3–4 times daily.

Transdermal (Adults): Postherpetic neuralgia:  Apply up to 4 patches for 60 min (single use); may be repeated every 3 mo, as needed based on pain (should not be used more frequently than every 3 mo);  Diabetic neuropathy of feet:  Apply up to 4 patches for 30 min (single use); may be repeated every 3 mo, as needed based on pain (should not be used more frequently than every 3 mo).

Availability (generic available)

Cream: 0.025%^OTC, 0.035%^OTC, 0.075%^OTC, 0.1%^OTC

Gel: 0.025%^OTC

Lotion: 0.025%^OTC

Topical liquid: 0.15%^OTC

Transdermal patch: 0.0225%, 0.025%, 0.03%, 0.0375%, 0.05%, 8%

In Combination with: methylsalicylate (Ziks^OTC ). See combination drugs.

Assessment

• Assess pain intensity and location before and periodically during therapy.
• Assess skin (redness, irritation) for application burns.
• May cause temporary, minor reductions in sensory function. Assess patients with pre-existing sensory deficits or signs of sensory deterioration or loss prior to each application. If sensory deterioration or loss is detected or pre-existing sensory deficit worsens, reconsider continued use of capsaicin.
• Transdermal Monitor BP periodically during application.

Implementation

• Topical 

  Apply to affected area not more than 3–4 times daily. Avoid getting medication into eyes or on broken or irritated skin. Do not bandage tightly.

  • Topical lidocaine may be applied during the first 1–2 wk of treatment to reduce initial discomfort.
• Transdermal 

  8% product  (Qutenza) should only be applied by a health care provider.

  Examine area for lesions before application. Identify treatment area (painful area including areas of hypersensitivity and allodynia) and mark on the skin. If needed, clip hair (do not shave) in and around treatment area to promote patch adherence. Cut patch to size and shape of treatment area. Gently wash area with mild soap and water and dry thoroughly. Topical anesthetic may be applied to the entire treatment area and surrounding 1–2 cm; keep the local anesthetic in place until skin is anesthetized prior to the application of patch. Remove the topical anesthetic with a dry wipe. Gently wash treatment area with mild soap and water and dry. Administer in a well-ventilated area. Use a face mask and protective glasses during administration. Use only nitrile gloves when handling capsaicin and cleaning capsaicin residue from skin; latex gloves do not provide adequate protection. Apply patch to dry, intact skin. Apply patch within 2 hr of opening pouch. Tear pouch open along the three dashed lines and remove patch. Inspect patch and identify the outer surface backing layer with the printing on one side and the capsaicin-containing adhesive on the other side. Adhesive side of the patch is covered by a clear, unprinted, diagonally cut release liner. Cut patch before removing protective release liner. Peel a small section of the release liner back and place adhesive side of patch on treatment area. While slowly peeling back release liner from under patch with one hand, use other hand to smooth the patch down on to skin. Once patch is applied, leave in place for 60 min for postherpetic neuralgia and for 30 min for diabetic peripheral neuropathy. To ensure patch maintains contact with treatment area, a dressing, such as rolled gauze, may be used. Instruct the patient not to touch the patch or treatment area.

  • Even following use of a local anesthetic prior to administration, patients may experience substantial procedural pain. Treat acute pain during and following application with local cooling (ice pack) and/or appropriate analgesic medication.
  • May apply up to 4 patches at the same time. Do not apply more frequently than every 3 mo.
  • Remove patches by gently and slowly rolling inward. After removal, generously apply  Cleansing Gel  to treatment area and leave on for ≥1 min. Remove  Cleansing Gel  with a dry wipe, gently wash area with mild soap and water, and dry thoroughly. Aerosolization of capsaicin can occur on rapid removal of patches. Remove patches gently and slowly by rolling adhesive side inward. If irritation of eyes or airways occurs, remove affected individual from the vicinity. Flush eyes and mucous membranes with cool water. Inhalation of airborne capsaicin can result in coughing or sneezing. Provide supportive care if shortness of breath develops. If skin not intended to be treated comes in contact with capsaicin, apply  Cleansing Gel  for 1 min and wipe off with dry gauze. After  Cleansing Gel  has been wiped off, wash area with soap and water.

Patient/Family Teaching

• Topical 

  Instruct patient on the correct method for application of capsaicin. Rub cream into affected area well so that little or no cream is left on the surface. Gloves should be worn during application or hands should be washed immediately after application. If application is to hands for arthritis, do not wash hands for ≥30 min after application.

  • Advise patient to apply missed doses as soon as possible unless almost time for next dose. Pain relief lasts only as long as capsaicin is used regularly.
  • Advise patient that transient burning may occur with application, especially if applied fewer than 3–4 times daily. Burning usually disappears after the first few days but may continue for 2–4 wk or longer. Burning is ↑ by heat, sweating, bathing in warm water, humidity, and clothing. Burning usually ↓ in frequency and intensity the longer capsaicin is used. ↓ number of daily doses will not lessen burning but may ↓ amount of pain relief and may prolong period of burning.
  • Caution patient to flush area with water if capsaicin gets into eyes and to wash with warm, but not hot, soapy water if capsaicin gets on other sensitive areas of the body.
  • Instruct patient with herpes zoster (shingles) not to apply capsaicin cream until lesions have healed completely.
  • Advise patient to discontinue use and notify health care professional if pain persists >1 mo, worsens, or if signs of infection are present.
• Transdermal 

  Inform patient that treated area may be sensitive for a few days to heat (e.g., hot showers or baths, direct sunlight, vigorous exercise).

  • Advise patient that exposure of skin to capsaicin may result in transient erythema and burning sensation. Instruct patients not to touch patch; if they accidentally touch patch, it may burn and/or sting.
  • Instruct patient to notify health care professional immediately if irritation of eyes or airways occurs or if any side effects become severe.
  • If opioids are used to treat pain from patch, caution patient that opioids may cause drowsiness and to avoid driving or other activities requiring alertness until response to medication is known.
  • May cause transient ↑ in BP. Instruct patients to inform health care professional if they have experienced any recent cardiovascular event.
  • Rep:  Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Advise breastfeeding patient to avoid application to nipple and areola. Capsaicin is negligibly absorbed systemically following topical administration, and fetal exposure is not expected following maternal use.

Evaluation/Desired Outcomes

Decrease in discomfort associated with postherpetic neuropathy, diabetic peripheral neuropathy, rheumatoid arthritis, and osteoarthritis.

• Pain relief usually begins within 1–2 wk with arthritis, 2–4 wk with neuralgias, and 4–6 wk with neuralgias of the head and neck.