Module Three: Pharmacotherapy of Urinary System: Musculoskeletal Disorders
Pharmacotherapy Musculoskeletal Disorders
Module three case study is of a 59-year-old male who visited the office for pain management due a longstanding bilateral knee pain. The pain worsens with activity and when moving down the stairs. The pain affects his quality of life and is also worse when he is sleeping at night. He had an anterior cruciate ligament repair for the left knee 20 years ago. On examination, he is obese, and his knees are slightly swollen without redness or warmth bilaterally. He is currently on Lisinopril 10mg QID for his hypertension but has never seen a provider for the past five years. This patient is diagnosed with bilateral knee osteoarthritis.
The purpose of this paper is to describe the first-line nonpharmacological agent for him, explain all other pharmacological options, describe opioid prescription and osteoarthritis, describe the significance of acetaminophen use, provide patient education for this patient regarding the first-line medication, and provide a prescription sample for the patient.
First-Line Nonpharmacological Treatment
Osteoarthritis has long been considered a degenerative joint disease, but recent evidence has indicated the role of the inflammatory pathological process in the joints. Key risk factors are several but one that is outstanding in this patient is obesity. Therefore, first-line nonpharmacological treatment will aim to minimize the impact of this risk. Thus, the first-line non-pharmacotherapy will include lifestyle modification through physical exercise and weight management.
According to McCance and Huether (2018), weight reduction reduces the pain due to inflammation and when combined with physical activity, the beneficial outcome is greater. Therefore, the first-line therapy for this patient will be lifestyle modification for weight management and physical exercise.
Pharmacological Options for Osteoarthritis
Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually considered the first-line pharmacotherapy for OA. Topical NSAIDs formulations are ideal, especially for knee osteoarthritis. Some of the most commonly used NSAIDs include but are not limited to ibuprofen, ketoprofen, diclofenac, meloxicam, naproxen, and celecoxib. Acetaminophen has short-term and limited uses, especially for patients on anticoagulation therapy and in patients those with upper gastrointestinal disease.
Weak opioids have been used for short-term treatments but are less recommended due to their side effects. Other less recommended pharmacological options are nutraceuticals, such as glucosamine and chondroitin sulfate. Glucosamine and chondroitin are individual products that contain innate substances for cartilage formation. These products have been used to treat osteoarthritis by acting as a substrate for cartilage reformation, and reduction of cytokine production to reduce inflammation (Rosenthal & Burchum, 2020). Intra-articular steroid injections are used when the first-line pharmacotherapies fail to manage symptoms.
Role of Percocet
Percocet is an oxycodone-acetaminophen combination analgesic agent. Oxycodone is a selective opioid agonist at mu receptors with a risk for addiction, abuse, and toxicity. This patient asked the provider for Percocet for his pain because it had worked before. However, I think that this could suggest a dependence on Percocet. This patient’s pain is most probably chronic, and thus the use of Percocet would be a short-term strategy. Persistence and insistence on using Percocet would warrant a need for monitoring for misuse and opioid addiction.
Another suspicious issue about this patient is that he has never seen a provider in the past five years. Therefore, the source of Percocet is questionable. Percocet belongs to schedule II/IIN controlled substances and would require a prescription. I would respond to this patient’s request by explaining to him that his pain management should be related to the severity of his pain and that Percocet, a medication with a very high risk of abuse and dependence, would not be a good fit for his long-term pain management given that other medications down in the pain ladder have not been tried.
Pharmacological Management in Chronic Pain and Addiction
Addiction to analgesics in chronic pain management is a common public health problem that has caused significant mortalities, morbidity, and poor treatment outcomes. Therefore, monitoring opioid treatments and early screening for signs of dependence or addiction are evidence-based strategies with long-term mortality and quality-of-care benefits. With addiction comes the risk of fatal overdose among patients with knee osteoarthritis (Bodden et al., 2021).
Regularly scheduled office visits to reassess the level of pain is an excellent strategy to monitor outcomes of opioid use in chronic pain management. Using the lowest potent doses is advisable among opioid naïve patients. For opioid-dependent patients, detoxification, counseling, use of medications, reevaluation, and follow-up are key steps in treating undesirable outcomes. Naltrexone, methadone, and buprenorphine are the main medications used in the medication treatment of opioid addiction.
Different states have specific regulations and laws governing the prescription, use, and monitoring of opioid therapy in chronic pain management. My state, California, has a program called California’s Prescription Drug Monitoring Program (PDMP) which was named ‘CURES.’ The California Department of Justice administers CURES laws and regulations (Castillo-Carniglia et al., 2021). In 2016, the Controlled Substance Utilization, Review, and Evaluation System 2.0 (CURES 2.0) program in California implemented mandatory registration and proactive reports in California’s PDMP (Bureau of Justice Assistance, 2018).
This law requires that prescribers and pharmacists registered with the PDMP program. The generation of proactive reports to prescribers is a monitoring and quality control strategy to prevent mortalities and safety issues related to opioid prescription. In California, advanced practice registered nurses (APRNs), including nurse practitioners (NPs), can prescribe and dispense schedule II-IV medications that include opiates (Arizona Department of Health Services, n.d.). No physician collaboration is required to make these prescriptions. Therefore, my state is a full practice authority state that also accords NPs a full prescriptive authority.
Patient Education on the First Line Therapy
This patient’s first-line therapy will be Advil (ibuprofen) PO 200mg q6hr daily. Patient education will entail the indication for the use of this medication and the need for dose adjustment whenever pain is not well controlled on this minimal dose. The patient will also learn about the side effects of this medication, such as nausea, heartburn, ringing in the ear, headache, and dizziness. The patient will also be advised to take enough water daily, at least three liters daily, to prevent renal adverse effects of the drug.
The patient will also avoid other medications such as aspirin and alcohol use to prevent bleeding risk. The patient will contact the provider immediately when he experiences roaring in the ears, a change in urinary patterns, and no change in the subjective pain level. Lastly, the patient will understand the need to avoid overdose and the signs of overdose, such as headache, bleeding, and tinnitus.
Role of Acetaminophen
Acetaminophen is another short-term alternative pain reliever for this patient. However, it is not recommendable for this patient’s case. Acetaminophen will provide a marginal improvement in pain control but only for the short term. This patient’s pain is due to chronic illness and will require long-term pain control. According to Siebert et al. (2020), even higher doses of acetaminophen do not offer significant improvement. Some guidelines recommend the use of acetaminophen for mild to moderate OA. However, its benefits in terms of pain control are limited to short-term efficacies.
Role of Vitamin D and C Supplementation
Dietary recommendations for OA include increasing the intake of vitamin D and C intake among other nutritional elements such as n-3 fatty acids and fish oils (McCance & Huether, 2018). This strategy slows down cartilage degeneration and the progression of knee abnormalities. Long-term and consistent use of these vitamins slows disease progression (Joseph et al., 2020). I would recommend 400 IU once a week and vitamin chewable tabs at 250mg twice weekly for at least 4 years. The worsening of bone marrow abnormalities is also slowed down. To follow up, this treatment will include vitamin D and C assay levels at the first visit and monitoring during every visit every other month.
Conclusion
The patient’s OA was most likely related to his weight and familial risk. The most recommendable lifestyle modification included weight loss to prevent weight-loading and weight-bearing strategies. This patient also had opioid use issues that would need to be addressed ethically and professionally before initiating the NSAID treatment plan. Alternative medications were acetaminophen and weak opioids. However, these would have minimal benefits to this patient due to misuse and toxicity concerns. Weekly vitamin C and D supplementation would confer benefits in terms of reducing disease progression and worsening joint damage.
References
Arizona Department of Health Services. (n.d.). Appendix B: State-by-state summary of opioid prescribing regulations and guidelines. https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
Bodden, J., Joseph, G. B., Schirò, S., Lynch, J. A., Lane, N. E., McCulloch, C. E., Nevitt, M. C., & Link, T. M. (2021). Opioid users show worse baseline knee osteoarthritis and faster progression of degenerative changes: a retrospective case-control study based on data from the Osteoarthritis Initiative (OAI). Arthritis Research & Therapy, 23(1). https://doi.org/10.1186/s13075-021-02524-9
Bureau of Justice Assistance. (2018). Prescription drug monitoring program: California state profile. https://www.ojp.gov/ncjrs/virtual-library/abstracts/prescription-drug-monitoring-program-california-state-profile
Castillo-Carniglia, A., González-Santa Cruz, A., Cerdá, M., Delcher, C., Shev, A. B., Wintemute, G. J., & Henry, S. G. (2021). Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California’s prescription drug monitoring program. Drug and Alcohol Dependence, 218(108405), 108405. https://doi.org/10.1016/j.drugalcdep.2020.108405
Joseph, G. B., McCulloch, C. E., Nevitt, M. C., Neumann, J., Lynch, J. A., Lane, N. E., & Link, T. M. (2020). Associations between vitamins C and D intake and cartilage composition and knee joint morphology over 4 years: Data from the osteoarthritis initiative. Arthritis Care & Research, 72(9), 1239–1247. https://doi.org/10.1002/acr.24021
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby.
Rosenthal, L., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
Siebert, D. M., Cadwell Meyer, M., & Jensen, E. (2020). Acetaminophen for pain relief in osteoarthritis. American Family Physician, 102(2), 113–114. https://www.aafp.org/pubs/afp/issues/2020/0715/p113.html
Appendix A: Topical Prescription
| Pain Clinic
123, Main Street, Pain Center, CA |
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| Patient: Mr. AB
Age: 59 years |
Sex: male
Address: 123, Main Street |
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| Prescription: Ibuderm ® (Ibuprofen gel) 5% w/w topical
Indication: bilateral knee osteoarthritis Potential s/e: nausea, headache, ringing in the ears, dizziness, change in urine patterns and frequencies |
Your skin may become more sensitive to sunlight. Therefore, cover both knees when outdoors. | |
| Signature: apply over both knees three times daily
Take adequate amounts of water daily
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| Prescriber: Ms. AC, RN,
Signature: Date: December 7, 2022 Time: 0900hrs
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Address: Pain Clinic, 123 Main Street, CA | |