Trypsin-Chymotrypsin Dosing for Intervertebral Disc Bulge
The standard adult dose of trypsin-chymotrypsin for intervertebral disc bulge is 2 sprays under the tongue, 3 times daily, held for 30 seconds before swallowing, taken in 10-day cycles with 2-day breaks between cycles. 1
Standard Dosing Protocol
- Administration route: Sublingual (under the tongue) 1
- Dose: 2 sprays, 3 times per day 1
- Technique: Hold under tongue for 30 seconds before swallowing 1
- Timing: Take at least 20 minutes before or after food or drink 1
- Cycling schedule: 10 days on, 2 days off, then repeat 1
Critical Considerations for This Elderly Patient with Kidney Stones
Renal Function Monitoring
This patient requires heightened caution due to her history of nephrolithiasis and likely age-related renal impairment. Elderly patients commonly have reduced glomerular filtration rate (GFR declining approximately 1 mL/min/year after age 45-55), meaning an 80-year-old may have stage 2-3 chronic kidney disease despite "normal" creatinine levels. 2
- Baseline assessment needed: Creatinine clearance calculation using Cockcroft-Gault formula is essential before initiating therapy, as elderly women are particularly vulnerable to drug-related adverse events when renal function is impaired 3
- Enzyme accumulation risk: Serum trypsin levels are significantly elevated in patients with chronic renal failure and correlate with creatinine levels, suggesting impaired renal clearance of pancreatic enzymes 4
Specific Precautions for Nephrolithiasis History
- Fluid intake: Ensure high fluid intake (targeting urine volume ≥2.5 liters daily) as this is a mainstay of kidney stone prevention 5, 6
- Dietary sodium restriction: Limit sodium intake to 2,300 mg daily, as high sodium increases urinary calcium excretion and stone risk 5
- Calcium intake: Maintain dietary calcium at 1,000-1,200 mg daily from food sources (not supplements), as adequate calcium intake actually reduces stone formation by binding intestinal oxalate 5
Common Pitfalls to Avoid
- Do not assume normal renal function: "Normal" creatinine in elderly patients often masks significant renal impairment; calculate estimated creatinine clearance rather than relying on serum creatinine alone 3, 2
- Monitor for drug accumulation: Elderly women with reduced creatinine clearance (<30 mL/min) are at highest risk for adverse drug reactions related to impaired renal clearance 3
- Avoid nephrotoxic combinations: NSAIDs and other nephrotoxic agents should be avoided or used with extreme caution, as they markedly enhance toxicity when GFR is reduced 2
- Hydration during therapy: Inadequate fluid intake while taking any medication in a patient with stone history increases crystallization risk 6
Monitoring Requirements
- Renal function: Check baseline creatinine clearance and monitor periodically during therapy, especially if treatment extends beyond initial cycles 3, 7
- Stone recurrence surveillance: Question patient about flank pain, hematuria, or symptoms of renal colic at follow-up visits 6
- Medication review: Ensure no concurrent nephrotoxic medications that could compound renal stress 2