What is the appropriate management for a 42-year-old male patient with a healed fracture, retropatellar cartilage damage, and inadequate pain control with Cymbalta (duloxetine)?

From the Guidelines

The patient should continue with his current pain management regimen of meloxicam, Voltaren, Icy Hot cream, and Cymbalta, with no new orders being placed, as this approach maintains continuity of care while following institutional guidelines for medical equipment and medication management. The patient's fracture is healing well with significant progress since February 2025, and his left knee ligaments remain stable. However, he has retropatellar cartilage damage likely from the initial injury. The patient's requests for orthotic shoes and an egg crate mattress were denied as he does not meet Centurion guidelines for these items. The current egg crate mattress prescription will not be renewed once it expires. Regarding pain management, the patient reports Cymbalta 60 mg is not effective and wants gabapentin instead. He refused the offered increase in Cymbalta dosage, expressing a desire to improve his sleep. According to the study 1, gabapentin is effective for neuropathic pain, but it is not the first-line treatment. The American College of Rheumatology 2012 recommendations 1 suggest using acetaminophen, oral or topical NSAIDs, tramadol, or intraarticular corticosteroid injections for the initial management of knee OA. Some key points to consider in the patient's pain management include:

• The use of nonpharmacologic therapies, such as physical therapy and lifestyle changes, as recommended by the study 1
• The patient's current medication regimen, including meloxicam, Voltaren, and Cymbalta, which are all commonly used for pain management
• The potential benefits and risks of adding gabapentin to the patient's medication regimen, as discussed in the study 1
• The importance of following institutional guidelines for medical equipment and medication management, as seen in the patient's denied requests for orthotic shoes and an egg crate mattress. The decision to maintain current therapy rather than switch to gabapentin likely reflects a step-wise approach to pain management, ensuring that first-line treatments are optimized before moving to alternatives, as suggested by the study 1.

From the FDA Drug Label

Pain reduction was observed in patients both with and without comorbid MDD. However, the degree of pain reduction may be greater in patients with comorbid MDD. Neither trial demonstrated a benefit of 120 mg compared to 60 mg, and a higher dosage was associated with more adverse reactions and premature discontinuations of treatment

The patient is currently taking Cymbalta 60 mg in the evening, which is the first line of medication for nerve pain, but reports that it is not working. The patient refused to increase the dose of Cymbalta and instead wants to take Gabapentin. Key points to consider are:

• The patient's current dose of Cymbalta is 60 mg, which is the recommended dose for pain management.
• Increasing the dose of Cymbalta to 120 mg may not provide additional benefit and may increase the risk of adverse reactions.
• The patient's request to switch to Gabapentin should be considered, but it is not clear if Gabapentin would be more effective for this patient's specific condition. Considering the information provided and the patient's refusal to increase the dose of Cymbalta, it is reasonable to consider alternative treatment options, including Gabapentin. However, it is essential to weigh the potential benefits and risks of switching medications and to closely monitor the patient's response to any changes in their treatment regimen 2.

From the Research

Patient's Current Medication and Treatment

• The patient is currently taking Cymbalta 60 mg in the evening for nerve pain, but reports that it is not working 3.
• The patient is also taking meloxicam, which is a nonsteroidal anti-inflammatory drug (NSAID) used to manage rheumatoid arthritis, acute exacerbations of osteoarthritis, ankylosing spondylitis, and juvenile idiopathic arthritis 4, 5, 6.
• Additionally, the patient is using Voltaren, Icy Hot cream, and Cymbalta for pain management.

Gabapentin and Pain Management

• The patient has requested gabapentin, but there is no mention of it being prescribed or considered as a treatment option in the provided studies 3, 4, 5, 6, 7.
• According to the study on pharmacologic therapy for acute pain, adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate 3.

Meloxicam and NSAIDs

• Meloxicam is a selective inhibitor of cyclooxygenase-2 (COX-2) and is used to manage pain and inflammation in various conditions 4, 5, 6.
• The study on meloxicam in rheumatoid arthritis suggests that it has a lower risk of gastrointestinal toxicity compared to nonselective NSAIDs 6.
• The overview of pain management highlights the importance of understanding the characteristics of pain and the efficacies of available agents to best match them to the type of pain 7.