FamilyPAC Posted January 25, 2013 Share Posted January 25, 2013 New 80 y/o pt comes in with horrible degenerative joint disease of hands with CKD stage 3 AND a h/o of gastric ulcer. Takes aleve twice daily. I take pt off of it because of those reasons. Ultram makes him confused, hallucinates with hydrocodone, tylenol doesn't help pain and inflammation at all. I think I'm out of options!! Advice anyone? Thanks! Link to comment Share on other sites More sharing options...
Hemegroup Posted January 25, 2013 Share Posted January 25, 2013 pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf Here you go, this paper has been a big help in my pain management and I hope it helps you in yours as well. Referral to Pain Mgmt might be a good idea with this patient, due to age. Thanks to archerry for the article! Link to comment Share on other sites More sharing options...
KMD16 Posted January 25, 2013 Share Posted January 25, 2013 Consider topical option. Pain mgmt or rheumatologist referral. Link to comment Share on other sites More sharing options...
SocialMedicine Posted January 25, 2013 Share Posted January 25, 2013 do topical NSAID carry some GI risk too ? Link to comment Share on other sites More sharing options...
physasst Posted January 25, 2013 Share Posted January 25, 2013 First, I try to recommend non pharmacologic measures. If myofascial or muscular, try PT with modalities. TENS, US, Inferential, acupuncture, massage therapy..etc, etc.. If I need to use a medication, I tend to use Gabapentin for patients with CKD.....I know that it is excreted renally, but it is pretty safe, as long as you are cognizant of the patients GFR......Although it is still sometimes thought of as only effective for neuropathic pain, there is a lot of evidence that it is effective for arthritic and myofascial pain as well. I tend to adjust dosing as follows. Titrate up starting at 100mg TID to effectiveness, and if GFR is =/>50, they can advance to 900-3600mg TID...if the GFR is 30-50, I use 400-1400 BID. If GFR is 15-30, 200-700mg BID, and if the GFR is less than 15, I only use 100-300mg once daily. I always stick to the lower end of these doses, especially in the lower GFR range as many of them are kind of frail and usually elderly. Because of some of the side effects, IE; lightheadedness and fatigue, I worry about them falling.... That's what I do at least...Others may have some different thoughts as well... Link to comment Share on other sites More sharing options...
MedicinePower Posted January 25, 2013 Share Posted January 25, 2013 Sorry for the noobie question- what's CKD? Link to comment Share on other sites More sharing options...
Beorp Posted January 25, 2013 Share Posted January 25, 2013 Chronic kidney disease Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 25, 2013 Moderator Share Posted January 25, 2013 Sorry for the noobie question- what's CKD? CKD= Chronic Kidney Disease. It has various stages- the earlier stages simply being decreased glomerular filtration rate and increased baseline creatinine levels, and the extreme end being dialysis and possibly kidney transplant. Link to comment Share on other sites More sharing options...
MedicinePower Posted January 25, 2013 Share Posted January 25, 2013 CKD= Chronic Kidney Disease. It has various stages- the earlier stages simply being decreased glomerular filtration rate and increased baseline creatinine levels, and the extreme end being dialysis and possibly kidney transplant. Is it the same as Chronic Renal Failure? On the ambulance we have many, many patients who have CRF as a medical condition. I recall the GFR and creatine from my A&P classes. Doesn't one use inulin to check the GFR? Link to comment Share on other sites More sharing options...
Just Steve Posted January 25, 2013 Share Posted January 25, 2013 Have you folks had much luck with using Cymbalta for pain control? Link to comment Share on other sites More sharing options...
KMD16 Posted January 25, 2013 Share Posted January 25, 2013 Have you folks had much luck with using Cymbalta for pain control? As an add-on therapy in chronic pain pt. Link to comment Share on other sites More sharing options...
primadonna22274 Posted January 25, 2013 Share Posted January 25, 2013 pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf Here you go, this paper has been a big help in my pain management and I hope it helps you in yours as well. Referral to Pain Mgmt might be a good idea with this patient, due to age. Thanks to archerry for the article! Great article--I tucked it away for my upcoming renal rotation. Thanks :) Link to comment Share on other sites More sharing options...
FamilyPAC Posted January 25, 2013 Author Share Posted January 25, 2013 Thanks for the replies! I will take a look at that article Hemegroup. Link to comment Share on other sites More sharing options...
Joelseff Posted January 25, 2013 Share Posted January 25, 2013 do topical NSAID carry some GI risk too ? With voltaren gel I think its a 1.3% chance. IIRC. Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Joelseff Posted January 25, 2013 Share Posted January 25, 2013 Have you folks had much luck with using Cymbalta for pain control? I use it for OA, FM and neuropathic pain. But you have to give a faster acting analgesic to bridge them since it can take up to a month for results. Oh n thanx heme for the article! Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Just Steve Posted January 25, 2013 Share Posted January 25, 2013 Just finished up my FP rotation..one of the last patients we had was a young man with Complex Regional Pain Syndrome. Among the wide array of providers of whom he would frequent, somehow he ended up on Methadone. He came in to our clinic requesting a new script of Cymbalta at 120 mg/day dose to aid in his stepping down his Methadone. Sorry....getting off the topic of DJD with CKD. Link to comment Share on other sites More sharing options...
Joelseff Posted January 25, 2013 Share Posted January 25, 2013 Just finished up my FP rotation..one of the last patients we had was a young man with Complex Regional Pain Syndrome. Among the wide array of providers of whom he would frequent, somehow he ended up on Methadone. He came in to our clinic requesting a new script of Cymbalta at 120 mg/day dose to aid in his stepping down his Methadone. Sorry....getting off the topic of DJD with CKD. Never tried it on CRPS-these pts can be a nightmare- but it would be worth a try....Lyrica may also help... Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
bradtPA Posted January 25, 2013 Share Posted January 25, 2013 With voltaren gel I think its a 1.3% chance. IIRC. Sent from my myTouch_4G_Slide using Tapatalk And that's essentially the same as placebo. It's a good option. I would also consider a low dose butrans patchif they can afford it. Link to comment Share on other sites More sharing options...
physasst Posted January 25, 2013 Share Posted January 25, 2013 And that's essentially the same as placebo. It's a good option. I would also consider a low dose butrans patchif they can afford it. Butrans is a nice alternative, but it's so bloody expensive. Link to comment Share on other sites More sharing options...
mcneesejd Posted January 26, 2013 Share Posted January 26, 2013 We use low doses of morphine with renal dysfunction. I have worked in pain management for 5 years and methadone is our favorites for neuropathic pain. How much methadone is this guy on? Methadone is an NMDA antagonist which provides the ability to help decrease neuropathic pain and also by inhibiting NMDA, you become less tolerant to methadone compared too other opioids (don't have to increase dose frequently). I did my UNMC paper on prescribing methadone despite stigma and barriers if anyone is bored and wants to read 40 pages. Methadone IS NOT A BAD DRUG from a responsible prescriber (you don't need 100mg/day, 30-40 mg/day max). Now. what do I spent most of my time doing when it comes to pain management- helping people understand methadone's mechanism of action and use in opioid rotation. It does have a bad stigma but its unfortunate. When people voice concerns with methadone and what they have "heard." They usually describe zombie and drooling patients. Any opioid at high doses can do that. Any opioid in combination with non-prescribed narcotics, benzos, alcohol, illicit drugs- can cause this effect. Very rarely is it the drug itself. CRPS can be safely treated with opioid but treatment should be geared towards sympathetic blocks, spinal cord stimulator, intrathecal pain pump, or ketamine infusions. Cymbalta beyond 60mg is likely to just cause side effects in our experience. Link to comment Share on other sites More sharing options...
mcneesejd Posted January 26, 2013 Share Posted January 26, 2013 see réponse above Link to comment Share on other sites More sharing options...
mcneesejd Posted January 26, 2013 Share Posted January 26, 2013 Have you folks had much luck with using Cymbalta for pain control? Agree with KMD16, not much luck with it alone. Link to comment Share on other sites More sharing options...
Johnmortin3 Posted June 17, 2013 Share Posted June 17, 2013 While joint pain can be caused by a big variety of different issues, there are a some causes for chronic joint pain that are very common. They include: 1.Arthritis 2.Fibromyalgia 3.Ligament or tendon injuries of a severe nature Those are generally the four main reasons that you may be suffering from chronic pain in the joints. But before taking any supplements you can read reviews on web so that you can get some what good information about which supplement is good and which supplement is bad for chronic pain. You can read more chronic pain supplement reviews at "joint health magazine" website. Link to comment Share on other sites More sharing options...
bradtPA Posted June 17, 2013 Share Posted June 17, 2013 Pennsaid is another option, but pricey.... Link to comment Share on other sites More sharing options...
physasst Posted June 17, 2013 Share Posted June 17, 2013 Honestly, my primary response to most of these people is THERAPY, THERAPY, THERAPY. Just saw an international patient last week referred to me for low back pain, unfortunately, the pain wasn't due to the mild facet arthritis, but to pelvic floor dysfunction. Wrote a script for therapy. I'd say in a given week, I write 7-8 prescriptions for therapy for every 1 prescription for pain meds, and of the medications I write for, I maybe write for a narcotic 1-2 times per month. That's my approach. Link to comment Share on other sites More sharing options...
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