Impressions From Case 2

Benjamin W. Friedman, MD, MS: Let’s get everybody’s general impressions for how they would manage this case. Does anybody want to go first?

Jeff Gudin, MD: Clearly, this is a trauma patient with significant pain. One challenge is that for this type of nociceptive bone pain, we want an anti-inflammatory on board. It’s unfortunate that he didn’t tolerate the meloxicam. Then he throws in the kicker that he got too drowsy on oxycodone. He’s presenting as a challenging case. I go back to the basics. Let’s think about the nociceptive pathways. Could lidocaine patches over the ribs or some type of nerve blocks from the anesthesiologist give this patient some temporary benefit? Is there some other NSAID [nonsteroidal anti-inflammatory drug] that we might be able to get him to take? Is there some other opioid or opioid-like molecule that might be more tolerable to him? These are the things I think about when hearing about a challenging case like this.

Francesca Beaudoin, MD, MS, PhD: I’m thinking along the same lines as you, Jeff. Although at this point, I’m going to be a little shy about prescribing additional nonsteroidals based on the history of GI [gastrointestinal] ulcer and now exacerbated severe GI pain. We also hear that he doesn’t love taking pills, so he might be a candidate for a combination product. At this point, I might be thinking about something like hydrocodone and acetaminophen for him in addition to the other things you mentioned, such as lidocaine patches and some reassurance. It doesn’t sound as if he has any serious injuries, so we might expect that his course is going to get better. I’d recommend things like gentle movement and not lying in bed all day. There are nonpharmacological therapies we could initiate. That’s where my head would be.

Paul Arnstein, RN, PhD, FAAN: Although he’s on what I’d consider a subtherapeutic dose of acetaminophen, if you put him on a combination therapy of acetaminophen with an opioid, you’d have to have him stop that so that he doesn’t get too much acetaminophen on board. He had oversedation with oxycodone, so he doesn’t want that medication, but he says he’s done well on other narcotics. What were those other narcotics or opioids? Was it hydrocodone that he tolerated well? Then look at what that dose is, because these medications come in lower-dose forms. Find the right dose form. Once you get the fractures stabilized, although rib fractures are tough and have lingering pain, you’d expect the pain to be getting better incrementally with some of the nonpharmacological interventions, including gentle movements and other things that might be helpful for him.

Jeff Gudin, MD: If I remember the data correctly for celecoxib when the COX2s first came out and made a big hit, they weren’t completely absent GI effects, but they had fewer GI adverse effects than the traditional nonsteroidals. If I were going to put my toes back in the water with an NSAID, I’d probably reach for something like celecoxib. If I were to think about what type of opioid this gentleman might tolerate, I might go to something like buprenorphine or tramadol. We mentioned the combination of co-crystal with celecoxib and tramadol. That might not be a bad idea to consider for a patient like this.

Paul Arnstein, RN, PhD, FAAN: I agree. When you look at the literature for older adults, for people who have a history of GI ulcer, as this patient has, celecoxib and a PPI [proton pump inhibitor] in combination is what’s recommended in that vulnerable population. Considering a short course of that with a PPI during therapy might allow him to better tolerate the GI adverse effects of that medication.

With diabetes, one thing you might have to look at with the tramadol component of that medication is whether it affects his blood sugars, because there has been some association with hypoglycemic effects with patients who have diabetes. I’m not sure what diabetes medication he’s on, but monitor that in addition to some of the other monitoring that goes on for the short time that he’d be on that medicine.

Francesca Beaudoin, MD, MS, PhD: Paul, you bring up a great point about adverse effects. One thing I didn’t notice at the outset but that I’m looking at now as we’re talking about tramadol is the sertraline. That might give me a bit of pause regarding medication interaction with sertraline and tramadol in this case. In general, combination therapies have a role, but it’s important to apply it to the right patient. I’d want to know more about his sertraline use and that type of thing. For this person, we’re also talking about pretty short courses of medications, so we’re looking to maximize benefit and minimize adverse events during that period.

Transcript Edited for Clarity