What are typical medication prescriptions for a long-term care patient with pain, nausea, constipation, and cerumen (ear wax) impaction?

From the Guidelines

For a long-term care patient with multiple symptoms, a typical medication regimen might include acetaminophen 650mg every 6 hours as needed for mild to moderate pain, or tramadol 50mg every 6 hours for more severe pain, as recommended by the most recent guidelines 1.

Pain Management

• Acetaminophen 650mg every 6 hours as needed for mild to moderate pain
• Tramadol 50mg every 6 hours for more severe pain The use of opioids should be cautious and with reduced doses and frequency in patients with renal impairment, as suggested by 1.

Nausea Management

• Ondansetron 4mg every 8 hours as needed or promethazine 12.5-25mg every 6 hours Metoclopramide and antidopaminergic drugs are also recommended for treatment of opioid-related nausea/vomiting, as stated in 1.

Constipation Management

• A combination approach works best: docusate sodium 100mg twice daily as a stool softener, plus senna 8.6mg daily or bisacodyl 5-10mg daily as stimulant laxatives
• Polyethylene glycol 17g daily mixed in water can be added for more stubborn constipation Laxatives must be routinely prescribed for both the prophylaxis and the management of opioid-induced constipation, as recommended by 1.

Ear Wax Impaction Management

• Mineral oil drops (3-5 drops in the affected ear twice daily for 3-5 days) help soften the wax before removal Manual removal of cerumen is often preferred in patients with abnormal otologic findings, and the use of cerumenolytic agents during the week prior to the office visit can reduce potential side effects of suction removal, as suggested by 1.

This regimen addresses common issues in long-term care while minimizing side effects. The pain medications avoid opioid dependence when possible, antiemetics target different nausea pathways, and the constipation regimen combines softening and stimulating actions. Mineral oil works by softening hardened ear wax, making it easier to remove either naturally or during irrigation by healthcare providers.

From the FDA Drug Label

Tramadol hydrochloride has been studied in three long-term controlled trials involving a total of 820 patients, with 530 patients receiving tramadol hydrochloride Patients with a variety of chronic painful conditions were studied in double-blind trials of one to three months duration. Average daily doses of approximately 250 mg of tramadol hydrochloride in divided doses were generally comparable to five doses of acetaminophen 300 mg with codeine phosphate 30 mg (TYLENOL with Codeine #3) daily, five doses of aspirin 325 mg with codeine phosphate 30 mg daily, or two to three doses of acetaminophen 500 mg with oxycodone hydrochloride 5 mg (TYLOX® ) daily Ondansetron tablets are a 5-HT 3receptor antagonist indicated for the prevention of: nausea and vomiting associated with highly emetogenic cancer chemotherapy, including cisplatin greater than or equal to 50 mg/m 2. Patients with severe hepatic impairment: do not exceed a total daily dose of 8 mg.

For a long-term care patient with pain, nausea, constipation, and cerumen (ear wax) impaction, typical medication prescriptions may include:

• Pain management: tramadol (PO) at an average daily dose of approximately 250 mg in divided doses 2
• Nausea management: ondansetron (PO) at a total daily dose of up to 8 mg for patients with severe hepatic impairment 3
• Constipation management: no direct information is available in the provided drug labels
• Cerumen (ear wax) impaction management: no direct information is available in the provided drug labels

Note: The provided drug labels do not address the management of constipation or cerumen (ear wax) impaction. Therefore, no conclusion can be drawn for these conditions.

From the Research

Medication Prescriptions for Long-Term Care Patients

• For pain management, non-opioid alternatives and/or multi-modal pain control are recommended to avoid adverse effects associated with opioids, such as respiratory and central nervous system depression, nausea, vomiting, and constipation 4.
• Opioids may be prescribed for acute pain management, but their use should be carefully monitored due to the risk of tolerance, dependence, and misuse 4, 5.
• For constipation, treatment consists of both medical treatment with laxatives and non-medical treatment, with prophylactic use of laxatives indicated to prevent constipation when initiating constipation-inducing medication such as opioids 6.
• Education and training of healthcare staff on bowel care and constipation management are crucial in improving patient outcomes 7.
• For nausea, medication such as antiemetics may be prescribed, but the specific medication and dosage would depend on the individual patient's needs and medical history.
• For cerumen (ear wax) impaction, removal of the ear wax may be necessary to relieve auditory symptoms, but there is no specific medication prescribed for this condition 8.

Specific Medications

• Laxatives such as prucalopride, colchicine, or misoprostol may be effective in treating constipation 6.
• Opioid-antagonists such as naloxone and methylnaltrexone may be effective in patients with persistent opioid-induced constipation despite the use of laxatives 6.
• Non-opioid pain management strategies and multimodal regimens may include medications such as acetaminophen or ibuprofen, but the specific medication and dosage would depend on the individual patient's needs and medical history 4.