From the Guidelines
I strongly recommend prescribing naproxen and muscle rub for the patient's foot pain as requested, while also emphasizing the importance of proper foot care and monitoring for a patient with diabetes. The patient, a 48-year-old male seen in the prison OPC, reports discontinuing Zyprexa on April 26,2025, and wishes to delay A1C testing for 90 days due to Zypreza's known effect of increasing blood glucose levels. This is a reasonable approach, as olanzapine (Zyprexa) can indeed cause hyperglycemia and potentially affect A1C results 1. The patient will have an initial Chronic Disease Program appointment for diabetes management and anticoagulation therapy, where appropriate labs will be ordered.
For the foot pain, naproxen 500mg twice daily with food for 7-10 days would be appropriate, along with a topical muscle rub containing menthol or methyl salicylate to be applied to the affected area 3-4 times daily. The patient should be advised about potential gastrointestinal side effects of naproxen and to avoid using it long-term without medical supervision due to cardiovascular and renal risks. Additionally, the patient should be monitored for any interactions between naproxen and his anticoagulation therapy at his upcoming appointment. It is also crucial to educate the patient on proper foot care, including daily foot washing and drying, moisturizing dry skin, and cutting toenails straight across, as well as examining their feet daily for any signs of ulcers or pre-ulcerative lesions 1.
Some key points to consider in the patient's foot care include:
- Screening for signs or symptoms of peripheral neuropathy and peripheral artery disease (PAD) annually, or more frequently if the patient is at increased risk 1
- Educating the patient on how to protect their feet, including not walking barefoot or in thin-soled slippers, and wearing footwear that accommodates the shape of their feet and fits properly 1
- Considering coaching the patient to self-monitor foot skin temperatures once per day to identify any early signs of foot inflammation and help prevent a first or recurrent plantar foot ulcer 1
- Providing structured education to the patient about appropriate foot self-care for preventing a foot ulcer, including proper footwear and foot exams 1.
Overall, it is essential to prioritize the patient's foot care and monitor for any potential complications, while also managing their diabetes and anticoagulation therapy.
From the Research
Patient's Request for Follow-up
- The patient is requesting a 90-day follow-up after stopping Zyprexa, citing its effect on blood glucose levels 2, 3.
- Zyprexa, also known as olanzapine, has been associated with glucose dysregulation and an increased risk of developing type 2 diabetes mellitus 2, 3.
Follow-up Strategies
- The effectiveness of different follow-up strategies in adult cancer survivors has been studied, with varying results 4.
- Less intensive follow-up may make little or no difference to overall survival but probably delays detection of recurrence 4.
- Early outpatient follow-up with primary care has been associated with a reduction in 30-day hospital readmissions after acute ischemic stroke admission 5.
Medication and Treatment
- The patient is being prescribed naproxen and muscle rub for foot pain.
- The patient will have an initial CDP appointment for DM II and anticoagulation therapy, and labs will be taken care of during this appointment.
Relevant Studies
- A study published in 2000 reported a case of severe exacerbation of type 2 diabetes mellitus after the initiation of olanzapine therapy 2.
- Another study published in 2001 reported two cases of new-onset diabetes mellitus resulting after the initiation of olanzapine treatment 3.
- A 2022 study found that 90-day follow-up is inadequate for postoperative surveillance of fracture-related infections 6.