Question

Can someone please help me with these questions.

FH is a 52 yo male with c/o of chronic low back pain and bilateral knee pain for the past 10 years. Other past medical history includes atrial fibrillation, alcohol abuse (1/2 pint vodka daily), marijuana use (in remission), and depression. Active medications include Pradaxa 150mg BID, Zoloft 25mg daily, and acetaminophen 650mg q6 hours PRN. Patient states the pain affects his mobility and he is not able to exercise due to pain. Vitals include: weight 224lbs, height 68in, Blood pressure 132/82, Heart Rate 86bpm. Pertinent labs include serum creatinine 1.86, BUN 15, Liver Function Tests (LFTs)- AST 105, ALT 98, and glucose 80.

1. Why is acetaminophen not a good option for this patient? Select all that apply.

a. pain for over 10 years

b. alcohol abuse

c. use of Zoloft

d. heart rate over 80bpm

e. elevated LFTs

f. hypoglycemia

2. FH doesn’t like to take medications but asks if he can trial meloxicam 15mg daily as he has a friend that uses the medication with a good response. What is your recommendation?

a. No, due to the use of Pradaxa and reduced kidney function

b. No, due to the use of Zoloft for depression

c. No, due to glucose level and the risk of type II diabetes

d. No, because the patient has not been routinely tested for a meloxicam allergy

Answer 1

Ans : Acetaminophen is not a good option for this patient. Because -

a. The pain is chronic in nature, over 10 years. Acetaminophen is used in acute pain not chronic . Again medical history and description of pain suggests it to be neuropathic pain. Acetaminophen is used in acute musculo-skeletal pain. So in this condition where pain is over 10 years, acetaminophen administration is not a good choice.

b. Alcohol induces cytochrome P₄₅₀2E1 and increase potential toxicity of acetaminophen.

e. Elevated LFT indicates impaired hepatic function and hepato-cellular damage. Acetaminophen itself is hepato-toxic drug.In case of previously elevated LFT (hepatic damage persists) use of acetaminophen should be avoided.

On the other hand-

c. When the patient is using Zoloft ( an antidepressant of SSRI group) , co-administration of other Non-steroidal anti-inflammatory drug should be avoided (eg- aspirin, ibuprofen etc), but acetaminophen only is highly preferred in this condition.

d. Acetaminophen is preferred drug in patient with cardiac disorder.So heart rate over 80 bps does not discourage its use.

f. Acetaminophen is hepatotoxic and severe level of hepato-toxicity may lead to hypoglycemia. But there is no direct impact of hypoglycemia on acetaminophen (as it is mediated by hepatic failure, an ultimate state of acute poisoning). So there is no direct restriction of acetaminophen use in 650 mg dose when needed in hypoglycemic condition. Infact, in hypoglycemia other salisilate drugs are better to avoid.

Ans -  Meloxicam is a preferential  COX-2 selective non-steroidal anti-inflammatory drug.(NSAID) Though it more blocks COX-2 than COX-1 but at it therapeutic level it inhibit platelet in Thromboxane A2 production and thus lead to bleeding.

On the other hand, Pradaxa (Dabigatran) is an oral anti-coagulant that prevent coagulation.

So co-administration of this two drug for the long term increase risk of profuse and deadly bleeding . The bleeding risk will increase if there is associate hepatic or renal disturbance. Here reduced kidney function will decrease excretion of meloxicam and bleeding risk will be increased thus.

Co-administration of Zoloft also increase bleeding risk , so it may be another cause of avoid meloxicam use.

Meloxicam also show a risk of developing type II diabetes .

Meloxicam may also can cause serious type of allergy in some patients and may lead to anaphylotoxic shock. But such patients are also allergic to other NSAID s. The patient has a history of taking acetaminophen with a negative history of allergy development. So allergy to meloxicam can be excluded here.

So the most preferable option is - (a)