The disappointment of not being able to undergo a procedure to restore function can be overcome by attempting to improve the patient’s pain management in other ways. Stronger analgesics would not be desirable or appropriate in this case, unless Marie’s situation changes in the future.
Dr Annica Rhodin, pain clinician/anaesthesiologist, Uppsala, Sweden
The pain is due to arthritis and the dislocated cup of the hip prosthesis, including pain from tender muscles due to imbalance of position and gait. The history does not suggest any neuropathic component.
Secondary factors can arise from psychological distress, sleep disorder, and a difficult social situation, which seems to be of minor importance in this case. Advanced age and serious cardiovascular disease, including pharmacological treatment of these disorders, are limiting the treatment choices for this patient. We also have to respect her wish to stay alert and try as much as possible to avoid debilitating side effects, such as sedation, constipation, and dizziness.
The choice of a paravertebral or intra-articular block would not be considered by mainstream practitioners in Sweden. Limited evidence for efficacy and the risk of serious complications are the main arguments against these options. The fact that the patient herself is hesitant about these procedures adds further weight to the decision to abstain.
The mainstay treatment for osteoarthritic pain is paracetamol and NSAIDs. However, NSAIDs would not be recommended in this case, in view of the patient’s history of cardiovascular disease and the risk of interaction with aspirin and dipyridamole, as well as renal impairment in combination with losartan and diuretics.
Next in line are the opioids. Tramadol often causes severe side-effects in the elderly, such as nausea, dizziness, and disorientation, and should be discontinued. For continuing pain, a long-acting opioid in a tailored dose to minimise sedation would be appropriate, for example, slow-release transcutaneous buprenorphine or slow-release strong opioid in a very low dose, closely monitoring efficacy in relation to side-effects. Prophylactic laxatives should be instituted.
For breakthrough pain when moving on the affected hip, even strong opioids would be ineffective; it would be better to investigate whether bandaging and walking aids might help. Other non-pharmacological treatments, such as acupuncture and TENS, should be tried, to see if they can minimise muscular tension. Medication regimens should be reviewed, because many cause disturbing side-effects and interactions.
Dr Tzvetanka Petranova, Clinic of Rheumatology, Medical University, Sofia, Bulgaria
The reasons for pain in osteoarthritis are varied and complicated; they include synovitis, capsular tension, bone hypertension, muscular hypertonus, and enthesopathy.
Current treatment of osteoarthritis is mainly palliative and includes pharmacological and physical therapy, education, weight reduction and sometimes surgical approaches. Treatment should be tailored to the individual in consideration of factors such as age, comorbidity and use of medications. The drug of first choice is paracetamol. In patients with higher pain intensity and joint inflammation, NSAIDs, including selective COX-2 inhibitors, are more effective. It is possible to combine paracetamol and NSAIDs.
Myorelaxants, antidepressants, and benzodiazepines may be added to analgesic and anti-inflammatory therapy. In severe pain, opioids may be considered. The most commonly used opioids in osteoarthritic pain are tramadol, dihydrocodeine, fentanyl, and oxycodone.
Local application of corticosteroids should be used in case of synovitis and enthesopathy in activated osteoarthritis. Disease-modifying agents should also be considered, such as oral products based on glucosamine and chondroitin sulphate, and lubricants such as hyaluronic acid for intra-articular application.
In the present case, the patient could be hospitalised to receive complicated care. Choice of pharmacological therapy is limited by the concomitant diseases and medications. Selective COX-2 inhibitors or intramuscular parecoxib added to paracetamol are a possible choice. Oxycodone may be used for better pain control. Medical treatment can be combined with physical therapy and psychotherapy. Chondroprotection could be used simultaneously with other medications as long-acting disease- and symptom-modifying therapy.
Dr Joan Hester is consultant in pain medicine, King’s College Hospital, London, and president of the British Pain Society.
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