What is the most appropriate next step in treatment for an 18-year-old patient with a painful right ankle, significant swelling and bruising, and no fracture, who is currently taking paracetamol (acetaminophen) with inadequate pain relief?

From the Guidelines

The most appropriate next step in treatment for Alex Smith is to continue paracetamol 1g 4 times a day and add naproxen 550mg twice daily for two weeks as required. This approach is supported by the evidence from the British Journal of Sports Medicine 1, which suggests that the use of oral NSAIDs, such as naproxen, results in less pain in the short term without significantly increasing the risk of adverse events compared with placebo.

Key Considerations

• The patient's current pain management with paracetamol is inadequate, necessitating the addition of an NSAID to reduce pain and inflammation.
• Naproxen is a suitable choice, as it has been shown to be effective in reducing pain during motion in patients with mild-to-severe acute ankle sprains 1.
• The combination of paracetamol and naproxen provides a multifaceted approach to pain management, targeting both central and peripheral mechanisms of pain.
• It is essential to continue monitoring the patient's response to treatment and adjust the medication regimen as needed to minimize the risk of adverse events.

Additional Recommendations

• Alex should continue to follow the RICE protocol: Rest the ankle, apply Ice for 15-20 minutes every 2-3 hours, use Compression with an elastic bandage, and Elevate the ankle above heart level when possible.
• A supportive ankle brace or elastic bandage can provide stability during healing.
• Physical therapy should begin once acute pain improves, focusing on range of motion exercises and gradually progressing to strengthening.
• The patient should be advised to avoid alcohol while taking these medications and discontinue NSAIDs if experiencing stomach pain or black stools.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Carefully consider the potential benefits and risks of naproxen and other treatment options before deciding to use naproxen tablets. The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.

The most appropriate next step in treatment for Alex Smith would be to add naproxen to her current treatment regimen.

• The recommended dose is 500 mg initially, followed by 250 mg every 6 to 8 hours or 500 mg every 12 hours as needed for pain relief.
• Since Alex is 18 years old and has no renal or hepatic impairment, the standard adult dose can be considered.
• Continue paracetamol 1g 4 times a day as it is not contraindicated to use both medications together for pain relief.
• Option a) Continue paracetamol 1g 4 times a day and add naproxen 550mg twice daily for two weeks as required seems to be the most suitable choice, considering the dosage recommendations for naproxen 2.

From the Research

Treatment Options for Acute Ankle Pain

The patient, Alex Smith, is experiencing significant pain and swelling in her right ankle after a netball injury, with no fracture detected on X-ray. She has been taking paracetamol for pain management but is not experiencing adequate relief.

Current Treatment and Limitations

• The patient is currently taking paracetamol, which is a suitable first-line analgesic for mild to moderate acute pain, as evidenced by studies 3, 4.
• However, the patient's pain is not adequately managed with paracetamol alone, indicating the need for additional or alternative treatment options.

Alternative Treatment Options

• Naproxen: A nonsteroidal anti-inflammatory drug (NSAID) that has been shown to be effective in treating musculoskeletal disorders, including acute ankle pain 5.
• Combination therapy: Adding naproxen to paracetamol may provide better pain relief, as naproxen has anti-inflammatory properties that can help reduce swelling and pain.
• Oxycodone: An opioid analgesic that can be used for moderate to severe pain, but its use should be carefully considered due to the risk of dependence and side effects.

Recommended Next Step

Based on the evidence, the most appropriate next step in treatment would be to:

• Continue paracetamol 1g 4 times a day and add naproxen 550mg twice daily for two weeks as required, as this combination may provide better pain relief and reduce inflammation.

This approach is supported by studies 5, 3, 4, which demonstrate the effectiveness and safety of naproxen and paracetamol in treating acute musculoskeletal pain. However, it is essential to monitor the patient's response to treatment and adjust the medication regimen as needed to ensure adequate pain relief and minimize potential side effects.