From the Guidelines
The next step in managing this patient's chronic pain should be a comprehensive pain evaluation focusing on potential fibromyalgia, which is suggested by her widespread pain unresponsive to NSAIDs and duloxetine. I recommend starting pregabalin (Lyrica) at 75mg twice daily, gradually increasing to 150mg twice daily over two weeks as tolerated, while monitoring for side effects like dizziness and sedation, as suggested by the most recent guidelines 1. Additionally, a referral to physical therapy for a structured exercise program would be beneficial, emphasizing gradual aerobic conditioning and gentle stretching. Given her recent hysterectomy and pelvic organ prolapse history, pelvic floor physical therapy should be considered to address potential myofascial components, as recommended by recent studies 1. A pain psychology referral for cognitive behavioral therapy would help develop coping strategies. These approaches target central sensitization mechanisms likely contributing to her chronic pain syndrome, addressing both the neurological and musculoskeletal aspects of her condition. Sleep quality assessment is also important, as poor sleep can exacerbate pain perception and may require specific interventions. It's also worth noting that the evidence base for managing chronic pain is limited, and more research is needed to determine effective treatments for radicular low back pain, as highlighted in recent reviews 1. However, the current evidence suggests that a multidisciplinary approach, including pharmacological and non-pharmacological interventions, is the most effective way to manage chronic pain, as recommended by recent guidelines 1. Key considerations in managing this patient's pain include:
- Monitoring for potential side effects of medications, such as dizziness and sedation
- Addressing potential myofascial components of her pain through pelvic floor physical therapy
- Developing coping strategies through cognitive behavioral therapy
- Assessing and addressing sleep quality to optimize pain management.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Chronic Pain Management
The patient's history of chronic neck, back, and abdominal pain, unresponsive to nonsteroidal anti-inflammatories (NSAIDs) and duloxetine, presents a challenging case. Given the normal lab work, including complete blood count (CBC), creatinine, electrolytes, antinuclear antibody (ANA), ferritin, and rheumatoid factor (RF), and a history of pelvic organ prolapse with a recent hysterectomy, the next steps in management should focus on alternative treatments and further evaluation.
Alternative Treatments
- Gabapentin, as studied in 2, has shown efficacy in treating neuropathic pain, particularly in postherpetic neuralgia and painful diabetic neuropathy. Its use could be considered for this patient, given the chronic nature of her pain.
- The effectiveness of NSAIDs in chronic low back pain, as discussed in 3 and 4, suggests that while they may provide some relief, their efficacy is generally small, and their long-term safety profile is a concern. However, they could still be an option for short-term management.
- Duloxetine, as explored in 5 and 6, has been found effective for various types of chronic pain, including neuropathic pain and fibromyalgia. Despite the patient's initial unresponsiveness, the study 6 suggests that certain biomarkers might predict the efficacy of duloxetine, potentially warranting a reevaluation of its use.
Further Evaluation
- Given the patient's severe pain to the right anterior abdominal wall, a more detailed examination of the abdominal wall and consideration of other causes of abdominal pain, such as centrally mediated abdominal pain syndrome (CAPS) discussed in 6, might be necessary.
- The patient's history of pelvic organ prolapse and recent hysterectomy should also be considered in the context of her chronic pain, potentially indicating a need for a gynecological or urogynecological evaluation to rule out any contributing factors from these conditions.
Considerations
- The patient's lack of response to initial treatments suggests the need for a multidisciplinary approach, potentially involving pain management specialists, physical therapists, and psychologists to address both the physical and psychological aspects of chronic pain.
- The use of any medication should be carefully weighed against potential side effects and interactions, particularly given the patient's history of unresponsiveness or intolerance to certain medications.