NAMA : KADEK GITA DWI ANGGRAINI

NIM : 2208612057
KELAS :B

CASE-BASED LEARNING
PAIN MANAGEMENT

A 68-year-old female patient came for counseling with a pharmacist at the pharmacy on Saturday
morning. The patient complains of tingling pain in both the palms of the hands and feet.
Sometimes the pain is like burning and stabbing. The patient complains that the pain is more
pronounced at night and interferes with the quality of his sleep.
The patient had a history of uncontrolled diabetes, post-ischemic stroke, controlled hypertension,
and mild controlled osteoarthritis.

Patient's medication history:

• Metformin 2 x 500 mg (still continuing)
• Basal/bolus insulin 18 units (still continuing)
• Candesartan 1 x 16 mg (still continuing)
• Aspirine 1 x 80 mg (still continuing)
• Atorvastatin 1 x 20 mg (Continuing)
• Glucosamine 2 x 500 mg (still continuing)
• Gabapentin 1 x 300 mg (Already Stopped) The medicine is still left at home
• Amitriptyline 1 x 25 mg (Already Stopped) The medicine is still left at home
• Meloxicam 2 x 7.5 mg (Already Stopped) The medicine is still left at home
• Paracetamol 2 x 600 mg (Already Stopped) The medicine is still left at home
• Dexamethasone 2 x 0.5 mg (Already Stopped) The medicine is still left at home
The patient asked the pharmacist about the medicines he had left in his house, which he thought
he could use to relieve the symptoms of the pain he was feeling. If there is no medicine left that
can be used, the patient asks for a recommendation on what medicine he can buy temporarily to
relieve the symptoms of pain that is felt. The patient plans to have routine check-ups at the
hospital on Monday.
Case Questions:
1. What is the type of pain that the patient suffer?
2. Explain what things have the potential to cause pain to the patient!
3. Based on the remaining medicines in the patient's home, which drug is the patient's
choice to continue?
a) If YES, what medication do you recommend to continue?
b) If NO, what medicine do you recommend for the patient to buy?
4. Based on age, the patient belongs to the Geriatric category. In your opinion, what
medications should concern patients with geriatrics?

Answer
1. The patient complains of tingling pain in both the palms of the hands and feet. Sometimes
the pain is like burning and stabbing. The patient complains that the pain is more
pronounced at night and interferes with the quality of his sleep. The patient had a history
of uncontrolled diabetes, post-ischemic stroke, controlled hypertension, and mild
controlled osteoarthritis.
Based on the pathophysiology, the pain that the pastient complains is a Diabetic
neuropathy. Neuropathic pain commonly presents in primary care and one of its most
frequent causes is diabetes mellitus. A Pain arising as a direct consequence of
abnormalities in the somato-sensory system in people with diabetes. Neuropathic pain
results from abnormal functioning of the peripheral, central, or sympathetic nervous
systems.
2. Any things that have the potential to cause pain in the patient or (factors that induce pain)
are:
a) peripheral nerve fiber and microvessel dysfunction. This is primarily driven by
hyperglycemia and other metabolic factors, such as hyperlipidemia and impaired
insulin signaling, which lead to a variety of downstream pathogenic pathways. In
particular, hyperglycemia leads to overactivation of the polyol, glycation, protein
kinase C, poly (ADPribose) polymerase (PARP) and hexosamine pathways, all of
which contribute to oxidative stress in nerves and microvessels, it’s to be a factors
that induce pain in Diabetic Neuropathy (Smith et al., 2022)
3. The treatment of pain recommend for patients in the management of their pain is to
continue giving Gabapentin 1 x 300 mg. Gabapentinoids, including gabapentin and
pregabalin, are common anticonvulsants used in the treatment of neuropathic pain. There
are numerous formulations available with varying indications that may include diabetic
peripheral neuropathy (DPN), postherpetic neuralgia (PHN), fibromyalgia, neuropathic
pain associated with spinal cord injury (SCI), and restless legs syndrome (RLS). Based
on several neuropathic pain treatment guidelines, gabapentinoids are considered first-line
medications for the treatment of neuropathic pain (Dipiro, et al., 2020). gabapentin that
binds to presynaptic α 2δ subunit of calcium channels, possibly resulting in decreased
release of the excitatory neurotransmitters glutamate, noradrenaline, substance P, and
calcitonin gene-related peptide increase in the concentration of this neurotransmitter in
the synaptic cleft causes a decrease in the number of beta-adrenaline receptors which will
have an impact on reducing pain.(Pj et al., 2017)
4. Drugs that should be of concern to patients with geriatrics, both currently being used and
those that will be used, are:
a) The treatment of Aspirin 80 mg. Based on the American Geriatrics Society (2015)
drugs of concern to geriatric patients are drugs with the NSAID class, for example,
aspirin at a dose of >325 mg/day because it has side effects on digestive disorders
(American Geriatrics Society, 2019). The lowest dose of Gabapentin, which is 300
mg per day, can be given to geriatric patients (MMN Team, 2019). Based on this, the
treatment of Aspilet 80 mg and Gabapentin 300 mg is safe for use in geriatric
patients.
b) According to the patient, Patient used the drug Dexamethasone at a dose of 2 x 0.5
mg where corticosteroids and insulin have minor interactions which are antagonistic
pharmacodynamic mechanisms. The effect of insulin is to increase glucose input into
muscle and adipose tissue which causes blood glucose levels to decrease, while the
effects of corticosteroids are to increase insulin resistance, hepatic glucose
production, and inhibit glucose entry into muscle and adipose cells resulting in
increased blood glucose levels. Selective NSAIDs are said to have fewer
gastrointestinal side effects, but have a greater risk of cardiovascular side effects
(Pinzon, 2015).
REFERENCE
Alldredge, B. K., Corelli, R. L., Ernst, M. E., Guglielmo, B. J., Jacobson, P. A., Kradjan, W. A.,
& Williams., B. R. (2013). KODA- KIMBLE & YOUNGS Applied Therapeutics. In
Lippincott Williams & Wilkins.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel, et al. American Geriatrics
Society 2015 updated beers criteria for potentially inappropriate medication use in older
adults. Journal of the American Geriatrics Society. 63(11): 2227-2246.
DiPiro, J.T., G.C. Yee, L.M. Posey, S.T. Haines, T.D. Nolin, and V. Ellingrod, 2020.
Pharmacotherapy: A Pathophysiologic Approach. Eleventh Edition. McGraw-Hill.
Pinzon, R. 2015. Komorbiditas Nyeri pada Pasien Lanjut Usia. Cermin Dunia Kedokteran,
42(3):173- 175.
Pj, W., Derry, S., Rf, B., Asc, R., Tr, T., Phillips, T., & Ra, M. (2017). Gabapentin for chronic
neuropathic pain in adults ( Review ) SUMMARY OF FINDINGS FOR THE MAIN
COMPARISON. Cochrane Library, 6, 1–129.
https://doi.org/10.1002/14651858.CD007938.pub4.www.cochranelibrary.com
Smith, S., Normahani, P., Lane, T., Hohenschurz-Schmidt, D., Oliver, N., & Davies, A. H.
(2022). Prevention and Management Strategies for Diabetic Neuropathy. Life, 12(8),
1185. https://doi.org/10.3390/life12081185
Tim MMN. 2019. Basic Pharmacology and Drug Notes. Edisi 2019. Makassar: MMN Publishing