Advanced Pharmacology Sample Discussion
Discussion 1
For patients with acute musculoskeletal and soft tissue injuries, the most appropriate treatment choice for pain remains NSAIDs. However, since this patient reports being intolerant to NSAIDs and aspirin, the alternative medication would be a topical NSAID, such as diclofenac. While topical NSAIDs have been subject to extensive studies on efficacy with varying results, Busse et al. (2020) for non-low back musculoskeletal injuries, topical nonsteroidal anti-inflammatory agents offer the greatest benefits, “followed by oral NSAIDs and acetaminophen with or without diclofenac.” Unlike ordinary NSAIDs that must be used with caution in patients with a history of GI and Kidney problems, or intolerance, topical NSAIDs are safe alternatives. This is because they have a small amount of systemic absorption and yet offer pain relieving and anti-inflammatory benefits to patients.
- How would you prescribe them?
Prescribe Diclofenac 1.3% topical system. Diclofenac Topical Dosage (2019) recommends application of 1 topical system to the area with most pain, twice daily, for up to 7 days.
- What side effects should you educate the patient about?
Inform the patient that while this is a topical NSAID as opposed to an oral one, such side effects as GI symptoms may occur. Further, with application on the skin, irritation or rash may occur, prompting the need to notify the provider should it worsen. Educate the patient on proper usage as well, especially on the need to apply it on a clean dry skin, and not to wear the patch when showering. Inform the patient to always secure the patch with tape whenever it begins to peel off.
- Does the age of the patient influence what your choice?
The patient’s age to an extent influences the choice of treatment. Topical diclofenac is recommended for patients aged >6 years. However, there are no other age limitations associated with this medication.
Discussion 2
Metabolism and excretion of NSAIDs occur in the liver and through the kidney respectively. As such, these are the organs that are likely to incur damage. For this reason, it is important to assess liver and skin function prior to administering NSAIDs. Further, as Rakoski et al. (2018) observe, there is need to decrease the dosage when administering the drugs to patients with cirrhosis since they are likely to experience increased unbound drug levels and reduced clearance. Further education should regard patients with heart conditions as they are at increased risks of developing renal insufficiency, hence the need for close monitoring. Also, educate the patient on the risks of fluid retention caused by NSAIDs, which may result in changes in BP. Equally important is to educate the patient on the interaction between NSAIDs and other prescription medications, especially since many drugs tend to interact negatively with NSAIDs.
Taking too much aspirin can affect the liver. As such, it is advisable to monitor LFTs and continually assess the patient for liver dysfunction symptoms and jaundice. Patient education regarding aspirin use should cover self-monitoring of liver dysfunction signs and GI problems, especially GI bleeding (Lavie et al., 2017). To minimize the risks of GI bleeding, recommend the use of enteric coated aspirin. Educate the patient to monitor for such toxicity symptoms as tinnitus, impaired hearing and dizziness. The patient should stop Aspirin prescription immediately upon noticing the said symptoms.
3 Diagnoses for which NSAIDs would be appropriate:
- Muscle or Join pain following a sprain or strain
- Arthritis
- Postpartum pain
3 Diagnoses for which Aspirin would be ideal:
- Coronary Artery Disease
- Transient Ischemic Attack
- Angina Pectoris
References
- Busse, J. W., Sadeghirad, B., Oparin, Y., Chen, E., Goshua, A., May, C., Hong, P. J., Agarwal, A., Chang, Y., Ross, S. A., Emary, P., Florez, I. D., Noor, S. T., Yao, W., Lok, A., Ali, S. H., Craigie, S., Couban, R., Morgan, R. L., … Guyatt, G. H. (2020). Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials. Annals of Internal Medicine, 173(9). https://doi.org/10.7326/M19-3601
- Drugs.com. (2019). Diclofenac Topical Dosage. Accessed April 1st 2021 from https://www.drugs.com/dosage/diclofenac-topical.html
- Lavie, C. J., Howden, C. W., Scheiman, J., & Tursi, J. (2017). Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention. Current Problems in Cardiology, 42(5), 146–164. doi:10.1016/j.cpcardiol.2017.01.006
- Rakoski, M., Goyal, P., Spencer-Safier, M., Weissman, J., Mohr, G., & Volk, M. (2018). Pain management in patients with cirrhosis. Clinical Liver Disease, 11(6), 135–140. https://doi.org/10.1002/cld.711