From the Guidelines
The patient's decision to continue naproxen rather than starting duloxetine is reasonable, as both medications can be effective for pain management, and according to the 2021 study 1, NSAIDs have exhibited superiority to acetaminophen in those with moderate-to-severe OA pain. The patient's choice to continue with naproxen is supported by the evidence, which suggests that NSAIDs can be effective in managing OA pain.
- Naproxen works by reducing inflammation through inhibition of prostaglandin synthesis,
- while duloxetine acts centrally as a serotonin-norepinephrine reuptake inhibitor, as noted in the 2020 study 1. The bilateral intra-articular shoulder injections should provide localized pain relief by reducing inflammation directly in the joint space.
- The permanent nail removal procedure for his left great toenail should resolve any chronic issues with that nail, such as ingrowth or fungal infection, which can be particularly problematic in older adults. We will follow up to assess the effectiveness of these interventions and monitor for any complications, considering the patient's overall health and potential interactions with other medications, as recommended in the 2021 study 1. The use of duloxetine is conditionally recommended for patients with OA, but the patient's decision to decline it is acceptable given the potential benefits and risks, as discussed in the 2020 study 1.
From the Research
Patient Decision to Discontinue Duloxetine
- The patient has decided to discontinue duloxetine and instead continue taking naproxen to manage pain 2, 3.
- This decision may be influenced by various factors, including the patient's personal preferences, potential side effects, and efficacy of the medication.
Alternative Pain Management Options
- The patient will undergo bilateral intra-articular (IA) injections in the shoulders and a permanent removal of the left great toenail 2, 4.
- IA injections of hyaluronic acid (HA) and corticosteroid (CS) are a common treatment for osteoarthritis (OA) and may provide pain relief for the patient 2, 4.
Efficacy of Duloxetine in Pain Management
- Studies have shown that duloxetine can effectively relieve pain in patients with OA and improve knee joint function 3, 4.
- However, the patient's decision to discontinue duloxetine suggests that they may not have experienced significant pain relief or may have experienced adverse effects 5.
Considerations for Duloxetine Treatment
- Duloxetine treatment adherence can vary across different medical conditions, with higher adherence rates observed in patients with major depressive disorder (MDD) and generalized anxiety disorder (GAD) compared to those with chronic pain conditions 5.
- Patients with medical comorbidities, such as acute kidney injury or hepatic dysfunction, may require special consideration when taking duloxetine 6.