What is the appropriate pain management and sleep aid for a 77-year-old patient with Acute Kidney Injury (AKI) and hydronephrosis, who underwent a cystoscopy with stent placement, requests Tylenol (acetaminophen) and refuses narcotics due to constipation, and also requests Benadryl (diphenhydramine) for sleep?

From the Guidelines

For a 77-year-old patient with AKI and hydronephrosis who had a cystoscopy with stent placement today, I recommend acetaminophen (Tylenol) 500-650 mg every 6 hours as needed for pain, not exceeding 3,000 mg in 24 hours due to the patient's age and kidney injury. For sleep, diphenhydramine (Benadryl) 25 mg at bedtime is appropriate. The patient's preference to avoid narcotics due to constipation concerns is reasonable, as opioids can worsen constipation and may cause confusion in elderly patients 1. Acetaminophen provides adequate pain relief for many post-stent patients without gastrointestinal side effects and is safer in kidney injury than NSAIDs. The lower dose of Benadryl (25 mg rather than 50 mg) is recommended due to the patient's age, as elderly patients are more sensitive to anticholinergic side effects including confusion, dry mouth, and urinary retention. Some key considerations for pain management in this context include:

• The use of non-opioid analgesics as first-line treatment for mild to moderate pain, as recommended by recent guidelines 1.
• The importance of monitoring for and managing opioid-induced adverse effects, such as constipation, delirium, and nausea, if opioids are prescribed 1.
• The need for individualized pain management plans that take into account the patient's medical history, current condition, and personal preferences. Ensure the patient stays well-hydrated to help with both the AKI and to prevent urinary stasis with the new stent. It is also crucial to consider the patient's overall health status and potential interactions with other medications when selecting a pain management strategy. Given the most recent and highest quality study available 1, the recommended approach prioritizes the patient's safety, comfort, and quality of life.

From the FDA Drug Label

Do not use • with any other drugs containing acetaminophen (prescription or nonprescription). If you are not sure whether a drug contains acetaminophen, ask a doctor or pharmacist. • if you are allergic to acetaminophen or any of the inactive ingredients in this product. Active ingredient per 10 mL (1 Unit Dose) Diphenhydramine HCl 25 mg

For a 77-year-old patient with AKI and hydronephrosis who had a cystoscopy with a stent, and is requesting Tylenol (acetaminophen) and refusing narcotics due to constipation, and also requesting Benadryl (diphenhydramine) to help with sleep:

• Acetaminophen can be given as there are no direct contraindications mentioned in the label for this patient's condition, but it's crucial to ensure no other acetaminophen-containing drugs are being used concurrently 2.
• Diphenhydramine (Benadryl) can be considered for sleep aid, as there are no direct contraindications mentioned for this patient's condition, with the understanding that the active ingredient is 25 mg per 10 mL 3. Key considerations include monitoring for potential side effects and interactions, especially in elderly patients.

From the Research

Patient Request for Pain Management and Sleep Aid

The patient, a 77-year-old individual, is requesting Tylenol (acetaminophen) for pain management following a cystoscopy with stent placement, and Benadryl to aid with sleep. The patient is refusing narcotics due to concerns about constipation.

Acetaminophen Safety and Efficacy

• Acetaminophen is considered safe at therapeutic doses 4, 5, 6, 7, 8.
• However, it can cause severe liver injury and acute liver failure when taken in excess 4, 5, 6, 7, 8.
• The patient's request for Tylenol is reasonable, but it is essential to ensure that the dose is within the therapeutic range to minimize the risk of liver injury.

Considerations for Patient Care

• The patient's age and potential comorbidities should be taken into account when determining the appropriate dose of acetaminophen 6, 7.
• It is crucial to monitor the patient's liver function and adjust the treatment plan as needed to prevent liver injury 4, 5, 6, 7, 8.
• Benadryl can be used to aid with sleep, but its use should be carefully considered due to potential side effects, such as sedation and anticholinergic effects, particularly in elderly patients.

Pain Management Alternatives

• If the patient is concerned about constipation associated with narcotics, alternative pain management options, such as non-steroidal anti-inflammatory drugs (NSAIDs), could be considered 8.
• However, the use of NSAIDs should be carefully evaluated due to potential risks, such as gastrointestinal bleeding and renal impairment, particularly in elderly patients.