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Hi

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Suggestions for case study outcomes  as discussed at webinar

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Re JK
Age and wight?
Cumulative sedative effects increases the risk of falls. Combination of Li and diazepam: increased risk of neurotoxicity. Reassess zopiclone dose (if elderly, 3.75 mg the recommended dose).
Are the falls due to drowsiness/muscle weakness? Assess the need of senna (can cause hypokalaemia with weakness, fatigue, mscle cramps and pain), so again: risks of falls. Is she drinking enough, is she be dehydrated...confusion. Would need TFT, KFT, LFT, urine K levels

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MS
I agree, is this definitely gout? Is the swelling around the joint and does it feel hot. I would like to know a bit more about her lifestyle and diet. Does she suffer from any underlying conditions which increase risk of developing gout such as hypertension, cardiovascular disease ( care with NSAID) or diabetes. Is she taking any other regular prescribed medication such as diuretic which might precipitate gout? Am I therefore able to prescribe short course of colchicine?

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MS

Does the patient suffer from gout occasionally/regularly? has colchicine been tried before, what is the time scale of the pain - sudden/gradual, Urate levels? Ibuprofen - whats her medication taking behaviour/concerns/expectations? Ibuprofen may not be effective and may need changing to an alternative like indomethacin - but whats the local firmualry say/cost implications/contraindications/co-morbidities? once the gout pain has subsided - is she a candidate for allopurinol regularly? management plan after diagnosis/pain relief? does she like taking meds?

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Mrs AB

When the GP had said to increase dose of codeine to 60mg, how was the pt taking this?...may have been taking too many and thus the drowsiness..therefore would need to check understanding, Whats her medicine Hx, is she on regular paracetamol? Does she understand that codeine should only be taken alongside full dose paracetamol (will depend on weight of pt)...and when not in severe pain to leave codeine tablets, is the pt experiencing any other s/e from codeine (apart from drowsiness), OTC? What is the patients concerns, expectations, medication taking behaviour?

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Mrs JK . I  agree with you all. I will like to know the indication for each drugs , who prescribed them and how long she has been on them. Has she got a lithium booklet with record of her lithium level , TSH , U&Es to check for trends in  her result . Are they monitored regularly?. Is she under the care of the community psychiatric team or is she been monitored by her GP . whatever the  case, any review of her medication should be done jointly with the community psychiatric team as it is a specialist area . If pregabalin was  indeed started  for
neuropathic pain and she is not in pain then this should be consider for disprescribing. To be withdrawn gradually in agreement with the patient. Age and need for bone protection is also important

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Re: MS
I agree with Ebun, Clare and Desi . Need to know how long she had the pain for and if it is definitely gout. Cardiovascular disease need to be ruled out especially if NSAID is to be administered. Colchicine tend to be limited by diarrhoea . There is also the option of using  using oral corticosteriods like prednisolone for those who cant tolerate Colchicine or NSAID but used with caution with diabetes

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Re : AB
I also agree with Desi , Paracetamol is  usually first line  if there is no allergy or contra-indication i.e liver impairment. It should be  given regularly and it might be worth knowing her weight  so as to adjust the paracetamol dose accordingly (local Trust policy) .Is her continued pain the result of not taking codeine , is it worth her being changed to Oramorph to be given before any physiotherapy exercise. Topical analgesic is another option   It is also worth knowing  what other medication she might be on and if they have contributed to her fall

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Re: MS
I would firstly check for any systemic symptoms: fever, gen unwell to exclude septic arthritis (though unlikely if patient has had a gout attack in the past and recognises the symptoms and joint affected).
I'd check if max dose of medications has been taken; may consider using Indometacin instead of ibuprofen. Not sure what the benefit of colchicine would be unless started early on (would have to check).
Rest would be advisable during an acute gout attack. Also cold compress and elevation.
If no improvement within 2-3 days would refer for investigations (?via ED). If dramatically worsens should self-present to ED.

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Re: AB
In addition to the above points, I'd check allergy status (seems bizarre that she wasn't given paracetamol in the first place; could be allergic, although unlikely). Would check oxygen sats.
Safety netting - If experiences breathlessness or acute worsening of pain or generally unwell to seek urgent help.

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Re: JK

As suggested by Clare, Lofepramine seems an odd choice and may contribute to increased Lithium toxicity and increased sedation with Diazepam and Zopiclone.
I would check Li levels, U+Es, TFTs and discuss with patient how she feels about gradual lowering the dose of Lofepramine and Diazepam, explaining the potential risk associated with their use. I would seek specialist advice as I would expect that JK is (or has been) under psychiatry care.
Pregabalin - after checking indication for treatment I would again discuss with patient (and/or relative, carer) and consider gradual weaning.
I would suggest medication changes to be made one by one and gradually with patient's consent and ongoing monitoring.

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Would like to know who started meds and how they are being followed up. Has Lithium level been checked recently? What is the cause of falls - dizziness? cardiac? How old is JK? Has the increased toxicity of lofepramine wiith Lithium been considered? Why is sh taking Lithium? Is it possible to reduce the lofepramine to night time only to reduce daytime drowsiness? This is a high dose for an older person - how old is JK? Benzos e.g diazepam which has a long acting metabolite also increase risk of fall and generally should be considered for stopping if suffering from falls. What is the pregabalin really for? Is there any scope to remove this? Lots of drugs that increase risk of falls. If under psychiatry would want to discuss possibility of rationalising meds with her usual team. Any changes would need to be done carefully and her mental state evaluated regularly as each change is made. Complicated!

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How long has mrs MS had the pain? Is it definitely gout? - Do I need to arrange blood test for hyperuricaemia? How long has she been taking ibuprofen? Is she taking it regularly and has it been prescribed appropriately? Should  i check her eGFR?
Should I check her BP? Would like to ask if she has any cardiovascular disease (CI NSAIDS). Ha she been buying anything OTC and if so, what? Is this her first episode of gout?  Other than age, does she have any risk factors that would prevent me prescribing colchicine for her?

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How long ago did AB fall and has the pain in her ribs got worse?Any breathlessness? Has she been taking any other pain killer such as paracetamol? Codeine not appropriate due to drowsiness and increase risk of falls, also history of IBS. Would look at prescribing topical NSAID eg ibuprofen 5 or 10% gel

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Would like to know how long ago AB fell. If long time then would worry about the significance of ongoing pain - ? fracture. Would also be interested to know if takes any other meds - am suspicious that may be using anticholinergic e.g hyoscine/propantheline for IBS which may increase fall risk. She needs an alternative to codeine for her pain relief and I would like to consider a non opioid in the first instance as I would worry about the increased risk of falls with the drowsiness she has experienced with codeine. If I was to consider a NSAID, I would want to use for as short a time as possible because of increased GI risk (esp given her age) and would want to co-prescribe a PPI. NSAID would need to be used cautiously if she has significant dyspepsia (hiatus Hernia). Topical may be a possibility rather than systemic. I would like to know if she had any benefit from the lower dose of codeine and if she suffered dizziness at 30mg as if tolerated well, I may consider this with some regular paracetamol (NB still bearing in mind the increased risk of falls).

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Mrs JK. Is that pregabalin coded incorrectly? History of anxiety..would definietly want to check who started, when and why. Need to look at bloods for TSH/ Lithium/egfr. How old id she? post menopausal? Consider FRAX to calculate risk of osteoporosis,with view to DEXA to measure BMD given risk of falls...

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JK high risk of cumulative sedative effects, diazepam, zopiclone and lofepramine,  possibly falls are consequence of this. Consider ECG high dose of a tricyclic in the background of lithium, increased toxicity.

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Has AB been evaluated for any peritoneal involvement? Is there any associated breathless or radiation of pain? Patient history suggesting musculoskeletal and interstitial tissue aetiology, worth considering topical analgesia, Ibuprofen 5% gel apply TDS

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Re Mrs JK
Need to check Lithium levels to rule out toxicity.
Is JK taking all of her medicines as prescribed?

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Has MS been taking paracetamol and ibuprofen as prescribed? Has MS tried any other NSAIDs other than ibuprofen? What is Mrs MS's current renal function like? Is MS at risk of cardiovascular disease? Does MS have any co-morbidities that may preclude the use of NSAIDs such as high blood pressure, chronic kidney disease or heart failure? Has she ever had colchicine before or does she have any blood disorders that may contraindicate the use of colchicine?

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Re Mrs AB. Has paracetamol also been prescribed or is she on any other pain medicines? What other medications is she taking that may increase drowsiness?
What other medications is she taking that may increase her risk of falls?
Is she at risk of osteoporosis and does she need bisphophonate for prevention of fractures?

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Fall review

Mrs JK

 She has a history of  ++falls in last couple of years getting worse
and 4 falls this year already.

Currently
taking;

Priadel 200mg
OD

Pregablin 50mg
am & nocte recorded for osteoarthritis but on questioning JK states not in
pain.

Pregablin 25mg
lunchtime

Lofepramine
70mg OM 140mg nocte

Levothyroxine
75microg OD

Senna 2 ON

Zopiclone 7.5mg
ON

Diazepam 2mg BD

 

History of
anxiety.

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Fall review

Mrs JK

 She has a history of  ++falls in last couple of years getting worse
and 4 falls this year already.

Currently
taking;

Priadel 200mg
OD

Pregablin 50mg
am & nocte recorded for osteoarthritis but on questioning JK states not in
pain.

Pregablin 25mg
lunchtime

Lofepramine
70mg OM 140mg nocte

Levothyroxine
75microg OD

Senna 2 ON

Zopiclone 7.5mg
ON

Diazepam 2mg BD

 

History of
anxiety.

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 Patient MS

 

Mrs MS 68years
old

Community
referral from GP. Patient presented with swollen left foot & excessive
pain. Diagnosis of gout. Patient currently taking paracetamol & ibuprofen
with omeprazole cover.

Pain VAS 9/10.
Concern from therapist - cannot weight bear and participate in therapy.

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 Patient MS

 

Mrs MS 68years
old

Community
referral from GP. Patient presented with swollen left foot & excessive
pain. Diagnosis of gout. Patient currently taking paracetamol & ibuprofen
with omeprazole cover.

Pain VAS 9/10.
Concern from therapist - cannot weight bear and participate in therapy.

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Patient AB

 

Mrs AB 79years
old

Referred to
service following fall injuring foot and ribs

 

Asked by a
physiotherapist to r/v analgesia. Patient complaining of pain in ribs
was prescribed  codeine 30mg QDS during hospital stay. GP had advised to increase to 60mg since
pain in ribs still a problem.

PMH of hiatus
hernia and IBS.

Had stopped
taking codeine due to being drowsy during the day+++

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Patient AB

 

Mrs AB 79years
old

Referred to
service following fall injuring foot and ribs

 

Asked by a
physiotherapist to r/v analgesia. Patient complaining of pain in ribs
was prescribed  codeine 30mg QDS during hospital stay. GP had advised to increase to 60mg since
pain in ribs still a problem.

PMH of hiatus
hernia and IBS.

Had stopped
taking codeine due to being drowsy during the day+++