What is the best course of management for a patient with prediabetes, generalized anxiety disorder, left lower back pain, right knee pain, and fatigue, who is currently on bupropion and diclofenac?

Management of Musculoskeletal Pain in a Patient with Prediabetes and Anxiety

Discontinue diclofenac immediately and switch to topical diclofenac 1% gel applied to the affected knee 2-4 times daily, while addressing the back pain with non-pharmacologic interventions and evaluating for underlying causes of fatigue. 1, 2

Immediate Medication Changes

Discontinue Oral NSAIDs

• Stop diclofenac 75 mg immediately due to significant cardiovascular, gastrointestinal, and renal risks, particularly problematic in patients with prediabetes who are at elevated cardiovascular risk 1
• Oral NSAIDs should only be used at the lowest effective dose for the shortest duration possible, and this patient is on chronic therapy which is inappropriate 1
• The ACC explicitly recommends against ibuprofen and other oral NSAIDs in similar patient vignettes due to polypharmacy concerns and adverse event risks 1

Switch to Topical Therapy for Knee Pain

• Initiate topical diclofenac 1% gel applied to the right knee 2-4 times daily as the first-line pharmacologic treatment 1, 2, 3
• Topical NSAIDs provide equivalent pain relief to oral NSAIDs but with markedly fewer gastrointestinal adverse events and minimal systemic absorption 1, 2, 3
• Allow at least 4 weeks to assess efficacy before considering alternatives 3
• Topical diclofenac demonstrates superior efficacy to placebo with an effect size of 0.91 and shows small improvements in both pain and function after 8 weeks 1, 2

Back Pain Management

Non-Pharmacologic Approaches First

• Prioritize exercise therapy and physical therapy as the primary intervention for left lower back pain, as these provide moderate-quality evidence for improvement 1
• The CDC guidelines emphasize that nonpharmacologic approaches should be attempted before considering any systemic medications for chronic low back pain 1

Pharmacologic Options if Needed

• If non-pharmacologic interventions are insufficient after adequate trial, consider duloxetine 20-30 mg daily (starting low and titrating up) for back pain 1
• Duloxetine has moderate-quality evidence showing small improvements in chronic low back pain and would have the added benefit of potentially helping her generalized anxiety disorder 1, 4
• Avoid bupropion for pain management - note that the patient is on "bupsirone" (likely buspirone, not bupropion), but bupropion specifically has been shown ineffective for non-neuropathic chronic low back pain 5
• Oral NSAIDs can be considered for limited duration if duloxetine is contraindicated, but only at the lowest effective dose 1

Evaluate and Address Fatigue

Rule Out Secondary Causes

• Check HbA1c, fasting glucose, TSH, CBC, and comprehensive metabolic panel to evaluate for progression from prediabetes to diabetes, hypothyroidism, anemia, or electrolyte abnormalities 1
• Fatigue in the context of prediabetes warrants screening for diabetes progression, as this patient has multiple risk factors (elevated BMI, musculoskeletal complaints suggesting reduced activity) 1
• Consider that anxiety itself is highly prevalent in patients with prediabetes/diabetes (present in 40% with elevated symptoms) and can manifest as fatigue 6

Optimize Anxiety Management

• Reassess buspirone efficacy at current dose of 5 mg twice daily, as this is a relatively low dose and may need titration 4
• If anxiety remains poorly controlled and contributes to fatigue, consider augmentation strategies or switching to alternative agents with evidence in GAD 4

Prediabetes Management

Lifestyle Modification

• Emphasize weight loss, increased physical activity, and dietary modification as these will simultaneously address prediabetes, musculoskeletal pain (reducing joint loading), and potentially improve fatigue 1
• The patient's BMI indicates overweight/obesity, making weight loss particularly important for both metabolic and musculoskeletal outcomes 1

Monitoring

• Obtain baseline HbA1c and fasting glucose if not recently checked, and monitor at least annually given prediabetes diagnosis 1

Critical Safety Considerations

Avoid Polypharmacy Pitfalls

• This patient is at risk for the "guideline stacking" problem where multiple conditions lead to excessive medication burden 1
• Prioritize treatments that address multiple conditions simultaneously (e.g., duloxetine for both pain and anxiety if needed, weight loss for both prediabetes and joint pain) 1

Monitor for Drug Interactions

• If duloxetine is initiated, monitor for serotonin syndrome given concurrent buspirone use, though risk is low 4
• Duloxetine has minimal effect on glycemic control in patients without diabetic neuropathy, so prediabetes is not a contraindication 7

Treatment Algorithm Summary

1. Immediately discontinue oral diclofenac 1
2. Start topical diclofenac 1% gel to right knee 2-4 times daily 1, 2, 3
3. Initiate physical therapy and exercise program for back pain 1
4. Obtain laboratory evaluation (HbA1c, glucose, TSH, CBC, CMP) to assess fatigue etiology 1
5. Reassess buspirone dose adequacy for anxiety control 4
6. If back pain persists after 4 weeks of non-pharmacologic therapy, add duloxetine 20-30 mg daily 1
7. Emphasize lifestyle modification (weight loss, exercise, diet) for comprehensive management 1

Important Caveats

• Topical NSAIDs work best for superficial joints like the knee; they would be ineffective for hip or deep joint pain 3
• Custom-fitted orthoses for hand/thumb osteoarthritis require prolonged use (at least 3 months) to show benefit, but this patient does not have hand involvement 1
• The three-day duration of back pain suggests acute onset - ensure no red flags (fever, trauma, neurologic deficits, cancer history) that would warrant urgent imaging 1