Feb 26 2018 – Chronic Pain Case

Download Document: Chronic Pain Case Recommendations

 Date: February 26, 2018

PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise    establish  a  provider-patient relationship between any   ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.

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Case Synopsis:

70 year old woman that is high functioning with history of severe anxiety/depression treated with ECT and medication. History of renal cell carcinoma and resulting R nephrectomy in 2016. History of fibromyalgia with recent flare up of symptoms that patient described as being different than her usual flare up symptoms, likely polymyalgia rheumatic.

Summary of Recommendations:

1. Referral to rheumatology for long term management, adjustments – consider e-consult or contact directly if wait time is long for patient to be seen
2. Consider specific exercise program for fibromyalgia that can target exercises (i.e. stretching, strengthening, improving ROM) to improve symptoms.¹
3. Consider doing a bone scan – main concern of potential metastasis to bone with background history of renal cell carcinoma à consult with oncologist if needed
4. With history of osteoporosis and previous # of distal radius, consider starting patient on a bisphosphonate or denosumab – especially a concern with patient on prednisone
   7. Guidelines – if patient on average daily dose of 7.5 mg of prednisone for 3 months consider a bisphosphonateas high risk of fracture²
5. Use inflammatory and other biomarkers (i.e. CRP) to monitor and gauge:
   1. Any potential correlation with clinical symptoms
   2. Monitoring biomarkers when tapering off prednisone.
6. Involve psychiatrist as needed with regards to potential mood alterations while on prednisone.
   1. Consider starting patient on mood stabilizer (i.e. aripiprazole) to reduce risk of mania while on prednisone (discuss with psychiatrist if needed)
7. Alternative treatments to using prednisone to consider are methotrexate, hydroxychloroquine, TNFs or IL-6 to decrease inflammatory burden (Dr. J. Flannery’s suggestion), or may be useful to minimize prednisone dose.
8. Consider a slower taper of prednisone or keep patient on low dose of prednisone for longer–“downhill fast then slow”
9. If caregiver burden is present with regards to daughter, offer support options.

Resources:

1. Southlake Regional Healthcare –Fibromyalgia Education Program http://www.southlakeregional.org/Default.aspx?cid=1399&lang=1
2. Osteoporosis Treatment guideline http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf