Transcript Pain Case Presentation

A Case of Cauliflower Ears
Hilary Rowe, BScPharm
VIHA Pharmacy Resident 2009-10
Pain Clinic Rotation
Outline
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Objectives
Background
Patient Case
Clinical Question
Review of Evidence
Recommendation
Monitoring
Objectives
• Describe 1 way inflammation destroys
cartilage in relapsing polychondritis (RP)
• Name 3 risk factors for addiction in a
pain patient
• Be familiar with the evidence of disease
modifying agents in RP
Relapsing Polychondritis
• Destruction of cartilage and
replacement with fibrous tissue
• Autoantibodies to type II, IX, XI collagen
causes inflammatory infiltration
• Produce Th1 cytokines (TNF-α) by Tcell clones reactive to Type II collagen
• Lysosomal enzyme release eventually
results in destruction of the cartilage
Diagnostic Criteria
Presence of 3 or more:
• Recurrent chondritis both auricles
• Non-erosive inflammatory polyarthritis
• Nasal chondritis
• Ocular inflammation
• Respiratory tract chondritis
• Cochlear &/or vestibular dysfunction
Symptoms
•Respiratory tract 56%
•Audio-vestibular 46%
•Nasal chondritis 72%
•Cardiac and vascular 24%
•Ocular inflammation 65% •Auricular chondritis 89 %
•Polyarthritis 81%
•Skin lesions 17%
Treatment
?
Methotrexate, Colchicine,
Dapsone, Hydroxychloroquine
Treat inflammation-Prednisone
Treat pain-NSAIDS
Diagnosis
Mrs. MJ
• ID: 40 yo female, ht 155cm, wt 62kg
• CC: Acute decline in functioning with
widespread pain and stiffness in joints
• HPI Nov 2009: Current RP flare of
longest duration; walking this summer
and now in motorized wheel chair since
September
• RP diagnosed Aug 2009, polyarthritis
since 2005
Mrs. MJ
• PMHx: Transposition of ureters 1983Recurrent UTI’s (prior to surgery 89/year, after surgery 1-2/year)
• Allergies: Lactose (hives & difficulty
breathing)
Medications Prior to Assessment at Pain Clinic
Drug
Schedule
Indication
Tylenol #3
prn
Pain
Morphine sulfate 5mg
2 tabs daily
Pain
Codeine Contin 100mg SR 3 tabs bid
Pain x 3 yrs
Meloxicam 15mg
1 tab daily
Pain x 3 yrs
Colchicine 0.6mg
1 tab daily
Polychondritis x 1mo
Dapsone 100mg
1 tab daily
Polychondritis x 1 mo
Prednisone 5mg
8 tabs daily
Polychondritis x 3 yrs
Methotrexate 25mg/mL
1.1 mL inj sc weekly
Polychondritis x 3 yrs
Hydroxychloroquine
200mg bid
Polychondritis x 3 yrs
Medications Prior to Assessment at Pain Clinic
Trazodone 50mg
4 tabs at hs
Sleep
Duloxetine 60mg
1 cap daily
Depression & Pain x 4 mo
Senokot
prn
Constipation
Propranolol 20mg
1 tab bid
Graves Disease Tremor
Methimazole 5mg
1 tab daily
Graves Disease x 3 yrs
Pantoprazole 40mg
Daily
Cytoprotection
Zoledronic Acid 5mg
1 inj yearly March 2009 Bone Health
Calcium/Magnesium
3 tabs daily
Bone Health
Vit D 1000 units
1 tab daily
Bone Health
Mrs. MJ
• Social & Family Hx:
– Lives with husband & two teenagers
– Prior to attack was running an event
planning business
– Both parents were alcoholics
• Discharge Plan from Pain Clinic:
– Improve pain control & function
Medical Problem List
Active:
• Prolonged flare of RP
• Pain
• Constipation
Chronic:
• Depression • Osteopenia
• Graves disease
• Pain
• RP
Review of Systems
System
CNS
Findings
•Pain interferes with sleep
Medications
•Trazodone
200mg at hs
•1/4 -1/2 ounce
of Vodka
Psych
•Depression
•Fear of addiction
•Opioid Risk Tool : 5
•Duloxetine
60mg od
Score is 5:
•3 points family history
•1 point age
•1 point depression
Other factors:
•Drug seeking
•Altering routes
•Running out early
•Rx forgery
•Stealing
•↑ dose with no
change in disease
state
Review of Systems
System Findings
HEENT •Cauliflower ears &
occasional tinnitus
•Flat nose (RP
presentation), swollen &
painful
•Difficulty swallowing
Resp
•Unremarkable
Cardio
•Unremarkable
Medications
Review of Systems
System
Findings
Medications
GI
•Constipation- BM up to 1
week apart
•Senokot
•Pantoprazole
40mg od
GU
Bone Scan June 2009
•Right kidney 50% smaller
then left, could be related
to scarring
•Labs unknown
Liver
•Unremarkable
Review of Systems
System
Endo
Findings
•Graves Disease- Tremor
Heme
•Unremarkable
Fluids & •Unremarkable
Lytes
Medications
•Methimazole
5mg od
•Propranolol
20mg bid
Review of Systems
System
Findings
MSK
Bone Scan June 2009
Medications
•Methotrexate
•Mild arthropathies elbows, •Dapsone
•Colchicine
shoulders, hips, knees,
wrists
•Hydroxy•Mild active enthesopathies chloroquine
•Prednisone
shoulders, hips
Review of Systems
System
Findings
Medications
MSK
BMD 2009 Osteopenic:
•Zoledronic acid
5mg March
2009 (annually
x 3)
•Vit D 1000
units od
•Calcium
500mg
elemental tid
•-2.1 L spine, -2.1 L hip,
-1.7 femoral neck
•Risks: family hx, steroid
use, no weight bearing
exercise, Graves disease
Pain History
Paroxysmal attacks:
• Left side more affected then right
• Described: red-hot poker stabbing and
digging into her
• 20/10 causing her to sob, occurs with
flares
• What makes it better-? more medication
• What makes it worse- Nothing
Pain History
Baseline aches:
• Widespread: Nose, chest, sternum, jaw,
elbows, back, shoulders, wrists, hands,
hips, ankles
• Described: ache
• What makes it better-baths, medication
• What makes it worse- > 300-400 steps
per a day
DRPs
• MJ has a prolonged polychondritis flare
and is experiencing additional pain not
controlled by her current therapies
• MJ is experiencing constipation
secondary to narcotics and immobility
and could benefit from a regular bowel
routine
DRPs
• MJ has a prolonged flare of
polychondritis and could potentially
benefit from re-evaluation of her
disease modifying agents
Question
• Are there any disease-modifying
therapies that might be helpful for Mrs.
MJ’s prolonged flare of relapsing
polychondritis, taking into consideration
the medications she has already tried?
Therapeutic Options
•No change in therapy
•Infliximab
•Rituximab
•Azathioprine
•Cyclophosphamide
Clinical Question
P
40 yo female with relapsing polychondritis, with
an acute flare causing marked disability
I
Disease modifying agent
C
Placebo or current therapy
O
Reduce pain
Increase mobility
Slow progression of disease
Reduce morbidity and mortality
Decrease hospitalization
Search Strategy
• PubMed, Embase, Google
• Search terms:
– Relapsing polychondritis
– Disease modifying agents
– Autoimmune diseases
• Found
– 3 case reports, 1 retrospective review
Leroux et al. Arthritis & Rheumatism 2009
Design Retrospective review- 9 patients with RP
P
I
C
O
•6 females & 3 males
•Rituximab of varying doses and regimens
(1000mg 2 wks apart)
•None
•CRP & B cell levels
•Changes to steroids or immunosuppressant's
•CT thorax and inspiratory & expiratory flow
volumes
•Clinical evaluation
Leroux et al. Arthritis & Rheumatism 2009
Leroux et al. Arthritis & Rheumatism 2009
Results:
•2 partial remissions
•4 stable
•3 worsened
–2 added new immunosuppressants
–2 increased steroid dose
•6 benefitted- at 12 months 2 remained
stable & 4 were worse
Leroux et al. Arthritis & Rheumatism 2009
Limits:
•Retrospective chart review
•No standardized dose or regimen
•Small sample size
•No validated tool
•? 2nd course for partial remission at 6 mo
•1 patient died of sepsis at 7 months
Marie et al. Rheumatology 2009
Design Case Report
P
I
C
•38 year-old female with RP and an aortic
aneurysm in the abdominal aorta & thickening
of the abdominal aortic wall
•Infliximab 5mg/kg at weeks 0, 2, 6 and 8, then
5mg/kg every 8 weeks
•None
•Resolution of ocular inflammation
Results •Improved aortic impairment
•Asymptomatic at 3 years
Buonuomo et al. Rheumatol Int 2009
Design Case Report
•14 year-old female with RP- exacerbation of
P
episcleritis, ear involvement, throat pain,
dysphonia (laryngotracheal involvement)
I
•Infliximab 5mg/kg at weeks 0, 2 and 8
C
•None
•After 3rd infusion- acute respiratory distress
requiring intubation, mechanical ventilation &
Results low tracheostomy
•CT showed no difference in tracheal thickening
Richez et al. Rheumatol Int 2009
Design Case Report
P
•41 year-old male with RP and auricular and
vestibular relapse
I
•Infliximab 5mg/kg at weeks 0, 6 then q 8 wks
C
•None
•Chondritis, skin rash, dyspnea, episcleritis
resolved over 4 days
Results •Vestibular dysfunction & deafness NO change
•Before 5th infusion episcleritis returned
•No new flares at 1 yr & prednisone dose ↓
Goals of Therapy
Patients Goals
• Improve pain control
• Increase mobility and ADL
• Return to work
Team Goals
• Improve pain control
• Increase mobility and ADL
• Slow progression of disease
• Decrease morbidity & mortality
• Minimize adverse drug events
Recommendation
• No definitive evidence to support
suggesting a disease-modifying agent
• Risks and benefits of infliximab should
be discussed with patient
• Patient should make an informed
decision to start therapy
Recommendation
• Improve pain control
– Discontinue Codeine Contin
– Start Morphine 30mg long acting q
12h
– Start Morphine IR 5mg prn for
breakthrough pain
Recommendation
• Codeine Contin ineffective pain 20/10,
poor sleep, dose above ceiling effect of
400mg/day
• Morphine is effective for breakthrough
pain
• Morphine less potential for abuse then
hydromorphone and oxycodone
• SR formulation less potential for abuse
Monitoring
Efficacy
Monitor
Who
When
How Long
Pain Scale
rating < 20/10
> 400 steps a
day
↓ night time
awakening due
to pain & OH
use
Patient &
Pharmacist
Patient &
Pharmacist
Patient &
Pharmacist
Daily & at
refills
Daily & at
refills
Daily & at
refills
Duration of
therapy
Duration of
therapy
Duration of
therapy
Monitoring
Adverse Events
Monitor
Who
When
How Long
Constipation
< 1 BM q 2
days
Patient &
Pharmacist
Daily & at
refills
While on
narcotics
Day time
drowsiness
Patient &
Family
Daily
While on
narcotics
Drug seeking
behavior
Pharmacist
& Doctor
At refills
While on
narcotics
Follow Up- Feb 2010
• Patient switched from Codeine Contin to
Morphine (↓ IR 2 daily to 2-3 nights/wk)
• Currently ↓ prednisone dose
• Patient wanted to trial dapsone &
colchicine 1st (DMARD was not started)
• Patient now considering DMARD option
• Constipation improving
Questions?
References
1.
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5.
6.
Kahan M, Srivastava A, Wilson L et al. Misuse of and dependence on opioids:
study of chronic pain patients. Canadian Family Physician 2006;52:1081-87.
Marie I, Lahaxe L, Josse S, Levesque H. Sustained response to infliximab in a
patient with relapsing polychondritis with aortic involvement. Rheumatology
2009 Oct;48(10):1328-33.
Leroux G, Costedoat-Chalumeau N, Brihaye B, et al. Treatment of relapsing
polychondritis with rituximab: a retrospective study of nine patients. Arthritis
Rheumatology 2009 May 15;61(5):577-82.
Buonuomo PS, Bracaglia C, Campana A, et al. Relapsing polychondritis: new
therapeutic strategies with biological agents. Rheumatology International. 2009
Aug 15. [Epub ahead of print].
RichezC, Dumoulin X, Schaeverbeke T. Successful treatment of relapsing
polychondritis with infliximab. Clinical and Experimental Rheumatology
2004;22:629-31.
Porro GB, Lazzaroni M, Imbesi V et al. Efficacy of pantoprazole in the
prevention of peptic ulcers, induced by non-steroidal anti-inflammatory drugs: a
prospective, placebo-controlled, double-blind, parallel-group study. Digestive
and Liver Disease 2000 April; 32(3): 201-208.