A 43-year-old man using crutches went to the hospital complaining of leg pain. His medical history includes a fall on his right hip seven years ago, after which the pain began, and the discovered 75% tear of cartilage surrounding the hip joint. Symptoms include cramps with changes in the skin color and flexions of the toes. One of the neurologists the patient contacted diagnosed complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy (RSD). The family doctor denies RSD and is confident that the pain is of psychosomatic origin and caused by depression and refers the patient for a psychiatric examination. The man denies depression, and although he admits to some periodic sadness, he is confident that he can cope with it. The solutions proposed to the patient included Neurontin, later stopping the first drug, and administration of Zoloft, followed by the addition of Wellbutrin and Ativan.
The first decision for the treatment was to prescribe Neurontin (gabapentin) 300 mg at bedtime with a gradual increase in dose. This decision is justified since the drug is a standard solution for neuropathic pain management in CRPS (Money, 2019). Studies have shown that it has an inhibitory effect on voltage-gated calcium channels (Binder, 2021). As a result, Neurontin was expected to help reduce the patient’s pain. At the same time, side effects of spaciness and dizziness were possible (Binder, 2021). Therefore, the foggy feeling reported by the man was expected, but the medicine did not give the necessary pain relief. Moreover, the patient gave a high rate of the level of pain, indicating that the drug has no effect.
The second decision to treat the patient was to discontinue Neurontin and prescribe Zoloft (sertraline). This drug belongs to selective serotonin reuptake inhibitors (SSRI), which are considered a new generation of antidepressants and can be applied to treat chronic pain (OnuÈ›u et al., 2018). According to the evidence presented in various studies, as SSRI, Zoloft can affect serotonin levels and have an anti-inflammatory effect, affecting the patient’s pain (OnuÈ›u et al., 2018). As a result, the expectations for this decision were a reduction in pain in a man. Moreover, side effects were also characteristic of this type of drug; for instance, they included anxiety, sexual dysfunction, and agitation (OnuÈ›u et al., 2018). As the pain became more manageable, the subsequent decision was to correct and improve the current treatment.
Continuing treatment, the third decision was the addition of Wellbutrin (bupropion) and a short course of Ativan. The decrease in Zoloft was not considered, as the patient had improved pain management. The appointment of Wellbutrin is the evidence-based solution, as many studies prove a reduction in the side effect of SSRI-induced Erectile dysfunction (Yasin et al., 2019; Yee et al., 2018). Studies also support the justification for the short-term use of Ativan to reduce anxiety (Constable et al., 2022). These medicines can help the patient cope with side effects and control pain.
Thus, the patient’s treatment in the considered case focused on chronic pain management. The first decision to prescribe Neurontin failed, and the patient continued to feel severe pain. The second decision was the appointment of Zoloft, belonging to SSRIs, which are increasingly being considered for pain management. The medication showed a result in reducing pain but also caused some side effects. Therefore, the third decision, Wellbutrin and Ativan, aimed to minimize the side effects of continuing treatment with Zoloft.
References
Binder, M. R. (2021). Gabapentin — the popular but controversial anticonvulsant drug may be zeroing in on the pathophysiology of disease.American Journal of Clinical and Experimental Medicine, 9(4), 122-134. Web.
Constable, P. A., Al-Dasooqi, D., Bruce, R., & Prem-Senthil, M. (2022). A review of ocular complications associated with medications used for anxiety, depression, and stress.Clinical Optometry, 14, 13–25. Web.
Money, S. (2019). Pathophysiology of complex regional pain syndrome and treatment: Recent advancements.Current Emergency and Hospital Medicine Reports, 7(4), 203-207. Web.
Onuțu, A. H., Dîrzu, D. S., & Petrișor, C. (2018). Serotonin reuptake inhibitors and their role in chronic pain management. In Qu, Y. (Ed.), Serotonin (pp.1-22). IntechOpen. Web.
Yasin, W., Ahmed, S. I., & Gouthro, R. V. (2019). Does bupropion impact more than mood? A case report and review of the literature.Cureus, 11(3), 1-4. Web.
Yee, A., Loh, H. S., Ong, T. A., Ng, C. G., & Sulaiman, A. H. (2018). Randomized, double-blind, parallel-group, placebo-controlled trial of bupropion as treatment for methadone-emergent sexual dysfunction in men.American Journal of Men’s Health, 12(5), 1705-1718. Web.