History
Patient presents with a history of chronic right hip pain. The pain is associated with severe cramping of the right leg. He reports to have fell 7 years ago and landed on his right hip. After a battery of tests and investigation, a diagnosis of Complex regional pain disorder was made.
Treatment plan
Decision point one
I decided to put the patient on Amitriptyline 25 mg P.O at bed time with the aim of titrating the dosage upwards by 25 mg per week until a maximum dose of 200 mg per day would be reached. I made this decision based on the fact that Amitriptyline has been shown to be quite effective in treating neuropathic pain originating from a wide range of conditions. Research has estimated that Amitriptyline is effective in treating neuropathic pain in which is what our patient is suffering from in about 25% of cases as compared to placebo. In view of this, the drug has been used as the first line drug for neuropathic pain for years. It is noteworthy to note that it does not relieve neuropathic pain associated with HIV and cancer (Moore, Derry, Aldington, Cole, & Wiffen, 2015). Since our patient is not suffering from either of this, it is only prudent to try and manage the patient using this drug. My hope in giving this drug is that the drug would relieve the patient’s pain and enable him to walk around without crutches. I also hoped that it would help reduce the severity and incidence of cramping.
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Review after 4 weeks shows that the patient’s symptoms had improved as I had expected. Even though the patient was still using crutches, he reported that his pain had reduced and he rated the pain at 6/10. To my amusement, he further reported that at times that he was able to move around the house without a crutch. The frequency of cramping and curling of his toes had reduced. The only difference I observed is that the pain had not reduced as much as I had hoped in view of the efficacy levels reported in literature.
Decision point 2
After reviewing the patient, I was a bit impressed with the results but there was still room for improvement in terms of pain control to bring to a level of 3/10 as the patient desired. Also, there was need to deal with the side effect of feeling groggy in the morning since this would interfere with his daily routine.
In view of this, I decided to advice the patient to increase the dosage of the drug to 125 mg at bed time while still targeting 200mg per day and take the drug 1hr before bedtime. In making this decision, I was hoping that the increased dosage would help reduce the level of the pain thus making it possible to walk without the use of crutches. Further, I hoped that the frequency of cramping would reduce. By advising the patient to take the medication 1 hour prior to going to bed, I hoped that this would help reduce the feeling of being groggy in the morning since the body would have metabolized the drug by morning thus the concentration of the drug in the morning would not be as high which would explain the reduction in this symptom (Thour, 2019) .
True to my expectation the level of pain had reduced to 4/10 and the patient was feeling less groggy in the morning which enabled him to start his day earlier. All these findings correlated with what I had expect. Despite these positive findings, there was one drawback in that the patient was starting to gain excess weight. The weight gain was also an expected adverse effect of the drug and was therefore not a surprise (Domecq, et al., 2015).
Decision point 3
In view of these findings, I advised the patient to continue with the same drug dosage since the patient seemed to be getting relief of symptoms at this dosage. It is therefore prudent to continue at this dosage. Regarding the weight gain, I advised the patient to see a life coach to advice on diet and exercises.
By doing this, I hoped to continue suppressing the patient’s symptoms and fight the resultant weight gain through dietary control combined with exercises.
In 4 weeks’ time, I hope to see the patient’s pain being controlled and the weight gain also under control.
In treatment of this patient, I would ensure confidentiality such that only me and the patient knows what is going on (Herring, 2018). Ethics also demand that I prescribe to the patient the treatment modality with the greatest benefits and less side effects.
References
Domecq, J. P., Prutsky, G., Leppin, A., Sonbol, M. B., Altayar, O., Undavalli, C., … Murad, M. H. (2015). Drugs Commonly Associated With Weight Change: A Systematic Review and Meta-analysis. The Journal of Clinical Endocrinology & Metabolism , 100 (2), 363–370. doi: 10.1210/jc.2014-3421
Herring, J. (2018). 1. Ethics and Medical Law. Medical Law and Ethics . doi: 10.1093/he/9780198810605.003.0001
Moore, R. A., Derry, S., Aldington, D., Cole, P., & Wiffen, P. J. (2015). Amitriptyline for neuropathic pain in adults. Cochrane Database of Systematic Reviews . doi: 10.1002/14651858.cd008242.pub3
Thour, A. (2019). Amitriptylne . Statpearls Publishing.
