Question

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. What is the patient’s renal function using the standard Cockcroft-Gault equation?

a. 57ml/min

b. 67ml/min

c. 77ml/min

d. 87ml/min

2. The patient tries a knee and back brace for 60 days and does have good benefit for his knees but still with complaints of back pain. He sees a specialist and is diagnosed with lumbar radiculopathy and spinal stenosis. Patient complains of sharp shooting pain that can radiate down his legs. You want to try gabapentin. Based on patient’s renal function, what dose range would you recommend?

a. 100-300mg/day

b. 200-700mg/day

c. 400-1400mg/day

d. 900-3600mg/day

3. What are some non-pharmacologic modalities the patient could do to help with pain? Select all that apply.

a. Exercise

b. Healthy Weight Loss

c. See a Mental Health Specialist

d. Physical Therapy

Can someone please help me solve these questions.

Answer 1

Ans 1. Renal function is measured by Creatinine clearance rate. According to Cockcroft and Gault formula

C_Cr = [{((140 - age ) x weight ) / (72 x SC_r ) } x 1 (for male subject) ]

Here, C_Cr = Creatinine clearance (ml/minute)

Age = years

Weight = Kg

SCr = serum creatinine (mg/dl)

From the given data , Age = 52 years

weight = 224 lbs = (224 x 0.454 ) kg = 101.605 kg

Scr = 1.86 mg/dl

Therefore, Ccr = [{(( 140 - 52 ) x 101.6 ) / ( 72 x 1.86 ) } x 1 ]

= [{( 88 x 101.6 ) / 133.92}]

= 66.7622

  Patient's renal function is (b) 67 ml / min

Ans 2. Gabapentin is a GABA analog used in treatment of neuropathic pain. There are various dosing modifications of gabapentin related to renal impairment.

Ccr > 60 ml/min : 300-1200 mg TID (three times a day)

Ccr 30-60 ml/min : 200-700 mg BD (twice a day)

Ccr 15-29 ml/min : 200-700 mg OD (once a day)

Ccr <15 ml/min : 100-300 mg OD

So, in the given condition, Ccr is greater than 60. Gabapentine can be given as 300-1200 mg TID dosage form.

In this case total dose in a day is 300x3 - 1200x3 mg / day or 900-3600 mg/day

I would recommend (d) 900 - 3600 mg/day dose.

Ans 3. Non-pharmacological management of pain means interventions helps in pain management without drugs or medications. They are three types- physical, surgical and psycho-corporal or psycho-therapeutic.

There are various methods of pain management without medication -

Exercise, Balanced diet, Quit smoking and alcohol, Massage, Avoiding prolong pressure on nerve, Adaptive equipment, Magnet therapy, Hypnosis etc.

In the question there are four options, and all of them more or lass can act as non-pharmacologic modalities to relief the pain explained in the problem. For example- Exercise will improve flexibility and release pain to some extent, Healthy weight loss leads to decrease weight and workload on back and leg muscles and improve condition, Mental health specialist will distract mind and increase pain threshold of brain and give temporary relief.

But most effective is Physical therapy, because - it stabilize and improve symptoms by gently stretching the joints and muscles of spine to provide symptomatic relief.

So , d > a > b and c