The case study entailed a 43-year-old white man who presents with pain on the right leg. Due to the severity of the pain, the patient has to use crutches so as to be able to walk as he cannot walk unsupported. The patient reports that the pain started 7 years ago when he fell at his place of work landing on the right hip. From that time up until now, the patient has been to many doctors but he has never received any definitive treatment for his condition which made him to move from one doctor to another. Some diagnostic tests done on him revealed that his right hip cartilage was 75% torn from the 3 o’clock position to 12 o’clock position. Most surgeons that he has seen have been hesitant to carry out a total hip replacement on him as they feel that he is too young for the procedure as they think that the tear would heal naturally considering his age. The patient reports that he experiences a variety of symptoms resulting from his condition. Some of these include; cramping of the extremity, cooling of the extremity and pain. The patient was diagnosed by one psychiatrist with a condition called complex regional pain disorder. His family doctor refused to treat him as he sated that the condition emanates from depression and as a result, he was referred to a psychiatrist. Assessment of the patient revealed that he has no any mental illness as he did not exhibit signs of depression of a psychotic disorder.
Regarding this patient, I made 3 decisions. The first decision was to start the patient on savella 12.5mg once on day1, then 2.5mg BID on the second and 3 rd day, 25mg BID on day 4-7 and 50mg BID going forward. My goal when prescribing this drug was to help reduce the pain that the patient was having. This treatment helped the patient improve as was my expectation as the next visit after 4 weeks he came to the clinic without crutches. He rated the pain at 4/10 which was a great improvement. However, the patient experienced some side effects of the drug such a bout of sweating and elevated blood pressure and palpitations. I was expecting that the patient might experience some severe side effects from the drug hence this did not come as a surprise. At this point, my decision was to continue with the same medication but at a lower dose of 25mg BID. My decision to lower the dose but continue with the drug was to help in the relief of pain while taking care of the side effects (Daughton & Ruhoy, 201 3). After 4 weeks, the patient comes back to the clinic but this time he had his crutches on. His degree of pain had increased to 7/10. The client stated that the pain woke him from his sleep although the blood pressure had fallen to normal levels and he did not have any palpitations. I expected that the severity of side effects would reduce but I hoped that the pain would remain under control hence the fact that the pain increased was contrary to my expectation. At this point, my decision was to continue with savella 25mg in the morning and 50 mg at night. My rationale was that increasing the bedtime dose would help the patient sleep better by reducing the level of pain.
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The efficacy of using savella in the treatment of complex regional pain disorder has been investigated by numerous studies. A study by Derry et al. (2012) found that savella was effective in providing moderate pain relief to patients with chronic neuropathic pain at 40% compared to 30% placebo. However, the drug is associated with a greater risk of side effects especially when taken at high doses. These findings were refuted by another study by Derry et al. (2015) which reexamined the previous study and it was concluded that savella has no benefit in the treatment of neuropathic pain. Therefore, based on the recent study, it is true to state that my decision to treat the patient with savella was not evidence based.
RPS) References
Daughton, C. G., & Ruhoy, I. S. (2013). Lower-dose prescribing: Minimizing “side effects” of pharmaceuticals on society and the environment. Science of The Total Environment , 443 , 324-337. https://doi.org/10.1016/j.scitotenv.2012.10.092
Derry, S., Gill, D., Phillips, T., & Moore, R. A. (2012). Milnacipran for neuropathic pain and fibromyalgia in adults. Cochrane Database of Systematic Reviews . https://doi.org/10.1002/14651858.cd008244.pub2
Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for neuropathic pain in adults. Cochrane Database of Systematic Reviews . https://doi.org/10.1002/14651858.cd011789
