Home' Australian Pharmacist : Australian Pharmacist January 2017 Contents Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd. 51
CONTINUING PROFESSIONAL DEVELOPMENT
What medicines do you take for the pain?
Anna took anti-inflammatory medicines for several
years to relieve the pain of arthritis. However, the
general practitioner (GP) was concerned about
their effect on her stomach and changed Anna to
Panadol Osteo. Anna has recently had a fall that
has exacerbated her arthritis pain. The GP changed
the paracetamol SR to a combination product --
paracetamol and codeine -- but this did not control
the pain effectively. The GP changed Anna back
to paracetamol SR, added oxycodone 5 mg when
needed and also added tramadol 50 mg, to be taken
when the pain did not improve.
To gain a better idea of what is occurring, you ask
Anna the following questions in a general discussion
Are you taking any other medicines for pain relief?
Are you taking any complementary medicines?
Anna has tried fish oil capsules at a dose of 1 g fish
oil daily for pain relief, but this did not help. She
has not tried heat or exercises in a heated pool, nor
has she attended a pain clinic for assessment and
treatment of her arthritis. Anna does not find any
particular foods make her pain worse. One of her
friends has suggested turmeric capsules, but she is
reluctant to try these until she speaks with her GP.
Has the GP conducted any blood tests recently
and do you know the results?
Anna has regular blood tests as she has a history of
low iron due to heavy menstrual bleeding. The GP
did not comment that there were any issues when
she saw him for a full review a month previously.
Why are you taking the citalopram?
How long ago did you start citalopram 40 mg?
Anna has been taking citalopram 40 mg daily for
about 12 months, to treat anxiety and depression
related to her pain. She has not seen any other
doctors or specialists and has had the same GP for
over 20 years. Anna is no longer driving a car as she
feels disorientated, cannot settle and does not feel
herself. She does not feel unwell, but she feels very
confused. She mentions that when walking, she has
a peculiar gait. Anna describes her sleep as being
disturbed and she is having graphic nightmares,
which are unusual for her.
Anna appears to be suffering from a form of
delirium. There are a number of potential causes for
her current symptoms.1,2
Urinary tract infection -- Anna is not displaying any
other symptoms of a urinary tract infection and has
no frequency of urination. Her urine output is good
Constipation -- Anna states that her bowel
movements are normal.
Pneumonia -- Anna does not display any respiratory
signs or symptoms. During her recent complete
health check, she underwent a spirometry
assessment and her GP was pleased with her lung
Dehydration -- Electrolyte disturbances associated
with dehydration are a common cause of delirium.
Anna and her husband state that she drinks plenty
of water each day. She has also been drinking an oral
rehydration solution several times a day, as she has
been feeling quite nauseous of late.
Thyroid issues can contribute to reversible delirium.
Anna has had recent pathology performed by her
GP and her thyroid tests were normal. Anna has no
previous history of thyroid problems.
Concussion, stroke, or myocardial infarction --
Anna has not hit her head recently nor has she
had a stroke or heart attack. Her recent complete
health check showed she was in good health with
no abnormalities detected on her ECG. Her blood
pressure was normal and no abnormal heart sounds
Medicines -- Certain medicines (e.g. anticholinergics,
serotonergic agents), illicit drugs, and alcohol can
cause symptoms of delirium. Anna's symptoms seem
consistent with a delirium associated with serotonin
syndrome (see Table 1).4
"The GP changed
Anna back to
oxycodone 5 mg
and also added
tramadol 50 mg,
to be taken when
the pain did not
Table 1. Drugs that may contribute to serotonin toxicity when combined with tramadol
MAOIs (including moclobemide)
SNRIs (duloxetine, venlafaxine, desvenlafaxine)
SSRIs (citalopram, sertraline, fluoxetine, paroxetine,
Mirtazapine, St John's wort
Dextromethorphan, fentanyl, pethidine, tramadol,
Illicit drugs (e.g. 'ecstasy', LSD, cocaine), rasagiline, selegiline,
linezolid, lithium, methylene blue, tryptophan
References: Takeshita5;Sansone6;NSW Therapeutic Advisory Group7
Links Archive Australian Pharmacist December2016 Navigation Previous Page Next Page