What is the appropriate management for a 41-year-old female patient with a history of kidney transplant, intracranial hypertension, depression, hypertension, hyperuricemia, and hypothyroidism, presenting with headache and lower back pain, currently treated with Topamax (topiramate) and seeking referral to physical therapy and internal medicine for continued management?

From the Guidelines

The patient should be referred to physical therapy for evaluation and treatment of her lower back pain and to internal medicine for comprehensive management of her complex medical conditions, including her kidney transplant, intracranial hypertension, depression, hypertension, elevated uric acid, and hypothyroidism. The patient is a 41-year-old female with multiple chronic conditions, including a kidney transplant 12 years ago, intracranial hypertension, depression, hypertension, elevated uric acid, and hypothyroidism. She presented to the ER with a headache due to her history of increased intracranial pressure, currently being treated with Topamax (topiramate) under the care of Dr. Freedman and a neurologist from Mayo Clinic.

Key Considerations

• Her lower back pain has persisted for one year following a car accident, described as sharp and intermittent, worsening with prolonged sitting, and currently rated at 4/10 intensity.
• Although she initially declined physical therapy after her post-accident MRI, she is now requesting this service.
• A referral to internal medicine is recommended for comprehensive management of her complex medical conditions, which she is now willing to accept after previously declining.
• Her intracranial hypertension is currently managed with Topamax (topiramate), which was recently increased to 75 mg by Dr. Freedman.
• The importance of managing her hypertension is highlighted by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults, which notes that hypertension is common after kidney transplantation and may accelerate target organ damage and kidney function decline 1.

Management Plan

• Physical therapy would be beneficial for addressing her mechanical back pain through targeted exercises, manual therapy, and education on proper body mechanics, potentially reducing her pain and improving function without additional medication that might complicate her already complex pharmaceutical regimen.
• The internal medicine referral is particularly important given her transplant status requiring quarterly labs at Mayo Clinic and the need for coordinated care among her multiple specialists, including her transplant team, neurologist, and neuro-ophthalmologist.
• Mental health support is also crucial, as indicated by the KDIGO clinical practice guideline for the care of kidney transplant recipients, which recommends including direct questioning about depression and anxiety as part of routine follow-up care after kidney transplantation 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient's Medical History and Current Condition

• The patient is a 41-year-old female with a complex medical history, including a kidney transplant 12 years ago, intracranial hypertension, depression, hypertension, elevated uric acid, and hypothyroidism.
• She is being treated with Topamax (topiramate) for headaches due to increased intracranial pressure, and the dosage was recently increased to 75 by Dr. Freedman 2.
• The patient has a new neuro-optho specialist in Dallas, Dr. McHenary, and is being followed by a transplant team at Mayo Clinic, who require her to get labs drawn every three months.

Lower Back Pain and Request for Physical Therapy

• The patient is experiencing lower back pain, which started after a car accident and has been ongoing for 1 year, with sharp intermittent pain that worsens with sitting for long periods, currently rated as 4/10.
• She is requesting a referral to physical therapy for evaluation and treatment of her lower back pain, as previously discussed, but had refused internal medicine consultation for continued management of her complex condition, which she is now willing to consider 3, 4.

Management of Low Back Pain

• Studies suggest that most patients with acute/subacute low back pain will resolve regardless of the modality used or not, and routine imaging should be avoided in the absence of red flags 2, 5.
• The evaluation process, including history taking and physical examination, can produce small but significant therapeutic effects related to pain, fear-avoidance, and functional measures of mobility and sensitivity 3.
• Physical therapists should be familiar with specific signs and symptoms that may indicate serious pathology when evaluating patients with low back pain and refer for further investigation if necessary 4.

Hypertension and Kidney Transplant

• Hypertension is a major risk factor for atherosclerotic cardiovascular disease in kidney transplant recipients, and immunosuppressive agents can affect hypertension through various mechanisms 6.
• Calcium channel blockers may be useful in mitigating calcineurin inhibitor-induced vasoconstriction, and inhibitors of the renin-angiotensin system can be an attractive strategy for managing hypertension in transplant recipients, although close monitoring is necessary 6.