Page 55 - Demo

CONTINUING PROFESSIONAL DEVELOPMENT
MEDICATION MYSTERIES
Follow-up
Anna returns to the pharmacy in 2 weeks and asks for a Home Medicines Review the following month at the GP’s request. He has changed her medicines and asked that she takes the new medicine regimen for
4 weeks before the review is undertaken.
Anna has contacted the rehabilitation hospital and enrolled in their outpatient pain management classes under the direction of the occupational therapist and rehabilitation specialist. The GP and the rehabilitation physician have agreed to trial meloxicam 15 mg daily until the pain has eased. Tramadol has been ceased and paracetamol SR is to continue. Anna’s GP has agreed to trial high-dose magnesium.
Anna has had one session with the psychologist in the pain clinic and she is keen to try the program that he has outlined for the management of her pain. She is hopeful that upon completion of the program he has outlined, she may be able to reduce her dose of citalopram.
Anna and her husband have started a low-impact walking program with a group recommended by the rehabilitation clinic and she is feeling much more like her old self. She is enjoying walking with this group and feels that the session improves her mood as well
as her tolerance of her arthritis pain.7 She has visited the podiatrist, who has made her an orthotic and recommended a walking shoe for her. He has also shown her exercises for her calf muscles, and she stated that she no longer has pain in her toes and calves.
References
1. Alagiakrishnan K. Delirium. Medscape. 2016. At: http:// emedicine.medscape.com/article/288890-overview
2. Health in Aging. Delirium - causes and symptoms. 2014. At: www.healthinaging.org/aging-and-health-a-to-z/
topic:delirium/info:causes-and-symptoms/
3. Mayo clinic. Serotonin syndrome. 2015. At: www.mayoclinic.org/
diseases-conditions/serotonin-syndrome/basics/symptoms/
con-20028946
4. Medline Plus. Serotonin syndrome. 2014. At: www.medlineplus.
5. Takeshita J, Litzinger MH. Serotonin syndrome associated with tramadol. Prim Care Companion J Clin Psychiatry 2009;11(5):273.
9.
Mott J. Post operative pain – methods, challenges and the role of the pharmacist. SHPA Branch On Line CPD 09032016; 2016. Votrubec M, Thong I. Neuropathic pain - a management update. Aust Fam Physician. 2013; 42(3):92-7.
eTG complete. Melbourne: Therapeutic Guidelines; 2016.
1.5
CPD CREDIT
GROUP 2
The general practitioner (GP) has decided to discontinue citalopram while continuing with tramadol for managing a patient’s pain. Which of the following therapies would be MOST appropriate for management of the patient’s depression and anxiety? Replace citalopram with paroxetine.
Refer the patient to a psychologist. Replace citalopram with escitalopram. Replace citalopram with sertraline.
gov/ency/article/007272.htm
QUESTIONS
7. NSW Therapeutic Advisory Group Inc. Preventing and managing problems with opioid prescribing for chronic non-cancer pain. 2015.
8. Oates L. The evidence: omega-3 and -6 fatty acids, and turmeric. Australian Pharmacist 2016;35(10):50–3.
10.
4.
a) b) c) d)
KEY LEARNING POINTS
The management of pain for each patient will differ. The complex medicine regimens that are often required to manage pain can lead to adverse reactions and interactions such as serotonin syndrome. Patients with chronic pain often visit multiple prescribers, who may be unaware of the medicines prescribed by others or the potential for interactions that could occur. The patient often has a false sense of security that every person involved in prescribing their medicines and managing their pain has access to their complete medicine regimen, including past notes of suspected drug interactions or adverse reactions.
Serotonin syndrome does not occur for all patients taking combinations of serotonergic medicines, but there is a potential for the interaction. There
is a possibility of the interaction not being considered, as the symptoms could be mistaken for other medical conditions. Similar symptoms may also occur in patients taking high doses of certain opioids or high doses of antidepressants independently of each other.
Patients displaying symptoms that could be related to serotonin syndrome need to be referred to their GP for evaluation. Management of serotonin syndrome requires the following steps6:
• Remove the offending medicine.
• Provide supportive care until the accumulated medicine is removed from
the body.
• Trial serotonin antagonists (e.g. cyproheptadine) to alleviate symptoms.
• Treat the medical condition with therapy that will not raise serotonin
levels.
6. Sansone RA, Lori A. Tramadol: seizures, serotonin syndrome,
and coadministered antidepressants. Psychiatry (Edgmont) 2009;6(4):17–21. 11.
Each question has only one correct answer.
1. Which of the following symptoms may be part of the clinical presentation of serotonin syndrome?
a) Confusion, ataxia, agitation.
b) Hallucinations,tachycardia.
c) Rigidity, muscle spasm.
d) Alloftheabove.
2. Whichmedicalconditionlistedbelow is NOT associated with being a possible cause of delirium?
a) Urinarytractinfection.
b) Constipation.
c) Fractured ankle.
d) Dehydration.
3. Which of the following statements is INCORRECT?
a) Tramadol and citalopram have the potential to cause serotonin syndrome when taken alone.
b) Tramadol and citalopram in combination can cause serotonin syndrome.
c) Serotonin syndrome occurs only through increased serotonin synthesis.
d) Serotonin syndrome is caused by an accumulation of serotonin in the central and peripheral nervous systems.
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