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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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:
- Referral to rheumatology for long term management, adjustments – consider e-consult or contact directly if wait time is long for patient to be seen
- Consider specific exercise program for fibromyalgia that can target exercises (i.e. stretching, strengthening, improving ROM) to improve symptoms.1
- 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
- With history of osteoporosis and previous # of distal radius, consider starting patient on a bisphosphonate or denosumab – especially a concern with patient on prednisone
- Guidelines – if patient on average daily dose of 7.5 mg of prednisone for 3 months consider a bisphosphonateas high risk of fracture2
- Use inflammatory and other biomarkers (i.e. CRP) to monitor and gauge:
- Any potential correlation with clinical symptoms
- Monitoring biomarkers when tapering off prednisone.
- Involve psychiatrist as needed with regards to potential mood alterations while on prednisone.
- Consider starting patient on mood stabilizer (i.e. aripiprazole) to reduce risk of mania while on prednisone (discuss with psychiatrist if needed)
- 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.
- Consider a slower taper of prednisone or keep patient on low dose of prednisone for longer–“downhill fast then slow”
- If caregiver burden is present with regards to daughter, offer support options.
- Southlake Regional Healthcare –Fibromyalgia Education Program http://www.southlakeregional.org/Default.aspx?cid=1399&lang=1
- Osteoporosis Treatment guideline http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf