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PHAR 401 Pain Case (Tutorial #4)

Nov 14/11 @0945HRS ID Clinical Pharmacist Note MK is a 51-year-old previously healthy female librarian presenting to pain clinic for the first time with uncontrolled pain following a workplace injury after a metal shelving unit fell on her right arm 9 weeks ago. 1) Pain - c/o of shooting and stabbing pain which radiates up/down right arm; pulsates periodically; feels occasional numbness in right arm. Pain worsens when someone brushes up against arm. Pain limits patients ability to perform daily activities (e.g. putting clothes on, eating, perform job duties). - Has tried tramadol, ibuprofen, and naproxen with no improvement; denies current use of these medications. - Currently uses Tylenol #1 for pain; takes 8-9 tablets/dose and uses approximately 100 tablets every 3-4 days. Rates pain as 10/10 prior to and 9/10 after taking Tylenol #1. Patient acknowledges minimal relief with current regimen, but believes there are no other alternatives. - Patient denies any history of chemical dependency. 2) Mood - c/o depressed mood and fatigue. Has loss of interest in interacting with friends and family since the injury occurred. Patient reports suicidal thoughts, but does not have a plan. - Patient denies previous history of depression or psychiatric illness O - Patient is tearful with a sad facial expression; appears frustrated and defeated. - Patient guarding right arm/hand during interview. - Chart note from physical therapist indicates limited range of motion in right arm/hand. - Chart note from case manager indicates patient will not be able to return to work due to injury and will require re-training - All lab results and vitals WNL - Current meds are: 1) Escitalopram 10 mg daily (started 6 weeks ago) 2) Tylenol #1 (see dose as per patient above; started 4 weeks ago) - PharmaNet shows recent prescriptions filled for tramadol, ibuprofen and naproxen.

1) Neuropathic pain control - Patients symptoms consistent with neuropathic pain, and she has inadequate pain control on current regimen - Requires reassessment of current drug therapy in order to reduce pain to a tolerable level and improve function - 1st line options for neuropathic pain = pregabalin, gabapentin, tricyclic antidepressants (e.g. amitriptyline) - Pregabalin has official indication for neuropathic pain, convenient dosing regimen, no significant drug interactions, WorkSafe BC coverage; will need to monitor for sedation, weight gain, edema, dry mouth - Pregabalin side effects can be minimized by titrating dose slowly (q 3 days) 2) Tylenol #1 overuse - Opioid narcotics are not drug of choice for neuropathic pain and patient overusing Tylenol #1 (exceeding daily 4 g maximum for acetaminophen) - Currently uses ~30 Tylenol #1 tablets/day ( 240 mg codeine phosphate/day) - Need to slowly taper codeine dose to prevent withdrawal (i.e. reduce total daily codeine dose by 10-15% every 3-7 days), with eventual goal to discontinue codeine - Taper by switching from Tylenol #1 to an equivalent codeine dose given as longacting (i.e. Codeine Contin) + short-acting (i.e. codeine phosphate) combination to provide baseline + breakthrough pain control - Acetaminophen may have opioid-sparing effects, but total daily dose needs to be lowered to within safe range 3) Depression - Patients depressed mood and suicidal thoughts suggest that current antidepressant regimen is ineffective - Requires reassessment of drug therapy to achieve remission, restore patient optimal functioning, and prevent suicide - Escitalopram is an appropriate 1st line drug choice, however current dose (10 mg/day) is subtherapeutic, and there is room to increase dose - Patient denies any side effects from escitalopram, therefore reasonable to continue for now (and not switch to another drug) 1) Discontinue Tylenol #1 2) Start new pain medication regimen today: - Tylenol Arthritis 650 mg ii PO Q8H at 7am, 3pm, 11pm - Codeine Contin 50 mg PO Q8H at 7am, 3pm, 11pm - Codeine phosphate 15 mg PO BID PRN breakthrough pain 3) Increase escitalopram to 20 mg PO OD 4) Give patient a 7-day supply of all medications; patient to return to clinic in 7 days for follow-up appointment 5) At next follow-up appointment, will plan to start pregabalin 25 mg PO OD x 3 days (with plan to titrate dose up by 25 mg/day every 3 days) 6) Will monitor for efficacy (reduced pain, improved mood, reduced fatigue, improved ability to participate in rehabilitation) and toxicity (drowsiness, constipation, GI upset, reduced sexual interest) 7) Will continue to re-assess pain management and codeine use at each follow-up, with eventual goal to discontinue codeine use

K. Seto, PharmD Pager #: 604-555-5555