Case: A middle-aged woman with polyarthritis and comorbid obesity
With Dr Barry Cole | 13 Dec 2015 | Print
Submitted by Dr B Elliot Cole, Consultant, Pain Education; Former Medical Director, Shoals Hospital Senior Care Centre, Alabama; Former Executive Director, American Society of Pain Educators; and Former Director of Education, American Academy of Pain Management, USA.
In this case study, Dr B Elliot Cole describes the pain management of a middle-aged woman with polyarthritis and comorbid obesity. The patient responds well to treatment with buprenorphine transdermal patch 20 mg.
Donna is an obese 52-year-old woman with advanced osteoarthritis of her hands, knees, ankles and back. She presents with increasing pain for the past 3 years, stating she was told by an orthopedic surgeon that she must wait a few more years, until her pain is no longer controlled with medication, before she may have joint replacement surgery.
She describes pain as often 7 out of 10 (using a 0-to-10 scale, where 0 signifies no pain at all and 10 signifies the worst pain imagined). Pain is exacerbated by performing activities of daily living, including prolonged standing, lifting, walking, carrying objects, writing, doing household chores, bending forward at the waist and dressing. Pain is partially relieved with acetaminophen, ibuprofen, oxycodone, rest, hot showers for her back and ice packs for her knees. Pain limits her willingness to engage in an exercise program to assist with weight loss. Her pain management is complicated by her underlying medication-controlled type 2 diabetes mellitus and mild hypertension.
Donna is a high school-educated mother of three teenage children, living with her medically disabled husband who collects social security benefits. She and her husband have difficulty paying bills and buying medication.
She takes oxycodone/acetaminophen 5/325 mg qid, metformin 1,000 mg bid and lisinopril 20 mg od. She does not consume alcoholic beverages, has not received psychiatric services and denies use of illicit substances. She smokes 10 cigarettes a day.
Donna’s physical examination shows that she weighs 45% more than her ideal body weight, and her vital signs are normal (pulse, 78/min; blood pressure, 130/85 mmHg; respirations, 14/min; temperature, 37.0°C). Her head, neck and throat are unremarkable and her lungs are clear. Heart is regular in rate and rhythm; free of rubs and murmurs. The abdomen is pendulant, with normal bowel sounds, non-tender and free of masses and organ enlargement. Her spine shows cervical and lumbar lordosis, limited lumbar range of motion, and lumbar paraspinal muscle spasm bilaterally. There is no spinal tenderness. Knees are moderately swollen, with reduced range of motion and moderate crepitus bilaterally. There is 1+ pedal edema. Osteoarthritic changes are present in her hands.
Neurologically, she has normal strength in her extremities, with muted (1+) deep tendon reflexes at her knees and no reflexes present at her ankles. Sensation is diminished for temperature and vibration distally in her lower extremities, with normal pinprick vs light touch discrimination.
Donna is offered several options for medically managing her pain. She chooses to start once weekly topical buprenorphine transdermal patch 10 mg. Donna is started at 10 mg, not 5 mg, as she is already acclimated to opioid therapy, taking 20 mg of oxycodone daily, has moderate pain that ranges from 5 to 7 out of 10 (usually 6) and is expected to last indefinitely, and needs around-the-clock treatment. She is advised to continue oral oxycodone/paracetamol four times daily for the first day, thereafter limiting her use to ‘as needed for breakthrough pain’ to see how well the buprenorphine transdermal patch works, being advised that the maximum effect will occur after 72 hours of wear.
Donna is advised to continue the laxative therapy she has taken for oral oxycodone/paracetamol. She is told to change the buprenorphine transdermal patch site of application weekly, not to reuse any site before 21 days, avoid intense external heat, contact her physician if she develops a fever >39°C, and to watch for skin irritation at the site of application.
Donna returns on the 4th day of buprenorphine transdermal patch use reporting pain ranging from 4 to 6 out of 10, and usually 5. She denies significant opioid-related side effects (including constipation) and is free of skin irritation at the site of patch placement. Her patch strength is increased to 20 mg.
On the 8th day of buprenorphine transdermal patch use, Donna reports pain ranging from 3 to 5 out of 10, and usually 4. She has no significant opioid-related side effects, but notes redness at the site of the first patch application and mild itching at the site of the second patch. The skin is otherwise healthy and free of blisters. She is advised to apply cool compresses to the first application site, and apply a skin moisturizer and over-the-counter 1% hydrocortisone cream. If itching is bothersome, she is told to take over-the-counter diphenhydramine 25 mg every 4 to 6 hours as tolerated. She continues with buprenorphine transdermal patch 20 mg, but is told to rotate to the third patch in 4 days using a new application site.
Donna returns on her 16th day of buprenorphine transdermal patch use. She is spontaneously smiling. Her pain ranges from 3 to 4 out of 10, and is usually 3. She has no significant opioid-related side effects. The over-the-counter diphenhydramine at bedtime stopped the itching, and moisturizer use and 1% over-the-counter hydrocortisone cream applied to application sites after patch removal has resolved the skin redness. She is told to continue using the 20 mg buprenorphine transdermal patches and to return in 30 days for further medication and monitoring.
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