From the Guidelines
The most appropriate therapy for this patient is gabapentin. This patient is presenting with classic signs of complex regional pain syndrome (CRPS), which developed following her hand fracture and casting. The symptoms of burning pain, edema, allodynia (pain on gentle touch), decreased range of motion, and temperature changes in the affected limb are hallmark features of CRPS. Gabapentin, an anticonvulsant medication, is considered first-line therapy for CRPS because it effectively targets neuropathic pain by modulating calcium channels and reducing the hyperexcitability of neurons. Treatment typically begins at a low dose (300mg daily) and is gradually titrated up to an effective dose (typically 1800-3600mg daily in divided doses), with adjustments based on pain relief and tolerability.
Key Considerations
- Opioids like oxycodone are generally avoided in CRPS due to limited efficacy for neuropathic pain and risk of dependence 1.
- Amlodipine, botulinum toxin A, and IVIG may have roles in specific cases but are not first-line treatments for CRPS.
- Early intervention with appropriate therapy is crucial for preventing progression and improving outcomes in this challenging pain syndrome.
- The provided evidence from 1 discusses rehabilitation practices but does not directly address the treatment of CRPS, making 1 and 1 more relevant for guiding treatment decisions in this context.
Treatment Approach
- Gabapentin is the preferred initial treatment due to its efficacy in managing neuropathic pain associated with CRPS.
- The dose should be adjusted based on patient response and tolerance, with a typical effective dose range of 1800-3600mg daily.
- Monitoring for side effects and adjusting the treatment plan as necessary is crucial for optimizing patient outcomes.
From the Research
Patient Presentation
The patient presents with a 1-month history of unremitting pain in the left hand and wrist, which began 1 week after the removal of a cast for a fracture of the fourth metacarpal. The pain is described as aching and burning, with a rating of 8 on a scale of 0 to 10. Physical examination reveals edema, pain on palpation, inability to fully close the hand, decreased skin temperature, and cool, dry tissue.
Diagnosis and Treatment
Based on the symptoms and physical examination findings, the patient's condition is consistent with Complex Regional Pain Syndrome (CRPS) 2. The treatment modalities available for CRPS include physical therapy, pharmacotherapy, and interventional techniques.
Pharmacotherapy Options
The patient has already tried ibuprofen and hydrocodone without alleviation of pain. Considering the available options:
- A. amlodipine: not typically used for CRPS or neuropathic pain
- B. botulinum toxin A: may be considered for CRPS, but not as a first-line treatment 2
- C. extended-release oxycodone: may be considered for neuropathic pain, but with caution due to the risk of addiction 3
- D. gabapentin: has been shown to be effective in reducing pain in patients with CRPS and neuropathic pain 4, 5, 6
- E. intravenous immune globulin: not typically used for CRPS or neuropathic pain
Recommended Therapy
Based on the evidence, gabapentin (option D) is the most appropriate therapy for this patient, as it has been shown to be effective in reducing pain in patients with CRPS and neuropathic pain 4, 5, 6.