What is the most appropriate pain reliever for a patient with a fracture, considering their medical history and potential complications such as impaired renal function, liver disease, or stomach ulcers?

Pain Management for Fractures

For most fracture patients, acetaminophen (up to 4 grams daily) combined with peripheral nerve blocks should be the foundation of pain management, with NSAIDs like ibuprofen reserved only for patients without renal impairment, cardiovascular disease, or gastrointestinal risk factors. 1, 2

First-Line Approach: Regional Anesthesia Plus Acetaminophen

Peripheral nerve blocks are the primary analgesic modality and should be implemented immediately for fracture pain, particularly in elderly patients and those with hip fractures. 1, 2

• Fascia iliaca compartment blocks or femoral nerve blocks provide superior pain control compared to systemic medications, with significantly reduced opioid requirements and fewer side effects. 1, 2
• These blocks reduce acute confusional state, chest infections, and time to first mobilization while improving patient satisfaction by 31%. 1
• Continuous catheter techniques are preferred over single-shot blocks for extended analgesia. 2

Acetaminophen 1000 mg IV or oral every 6 hours is mandatory baseline treatment for all fracture patients unless contraindicated, significantly decreasing supplementary opioid requirements. 1, 2, 3

• Maximum daily dose should not exceed 4 grams to prevent hepatotoxicity. 1
• Evidence from a randomized controlled trial demonstrates that acetaminophen alone provides non-inferior pain relief compared to acetaminophen plus tramadol after extremity fracture surgery (mean satisfaction 8.3 vs 8.5 on 11-point scale). 3

NSAIDs: Use With Extreme Caution and Specific Contraindications

NSAIDs should be avoided entirely in patients with renal impairment, cardiovascular disease, heart failure, or peptic ulcer disease. 1, 4, 5

Absolute Contraindications for NSAIDs:

• Any degree of renal impairment or creatinine clearance <30 mL/min 4, 2
• Active peptic ulcer disease or history of gastrointestinal bleeding 1, 4
• Heart failure or recent myocardial infarction 4, 5
• Age >60 years with cardiovascular risk factors 1
• Concurrent anticoagulant therapy 1

If NSAIDs Are Considered:

Ibuprofen 400 mg every 6-8 hours (maximum 3200 mg daily) is preferred over other NSAIDs when safer therapies have failed and no contraindications exist. 1

• High-quality evidence shows ibuprofen 400 mg combined with paracetamol 1000 mg provides 73% of patients with at least 50% pain relief (NNT 1.5), superior to either drug alone. 6
• Mandatory co-prescription of proton pump inhibitor is required for all elderly patients taking NSAIDs for gastrointestinal protection. 4
• Monitor blood pressure, renal function (BUN, creatinine), and liver function every 3 months during NSAID therapy. 1

Naproxen should be used rarely and only after safer therapies have failed in highly selected individuals, always with proton pump inhibitor co-prescription. 4

• NSAIDs were implicated in 23.5% of hospitalizations due to adverse drug reactions in older adults. 4
• Gastrointestinal toxicity is both dose-related and time-dependent, with serious upper GI events occurring in 1% of patients treated for 3-6 months and 2-4% treated for one year. 5

Opioids: Reserve for Breakthrough Pain Only

Opioids should not be first-line or sole analgesic for fracture pain and should be reserved strictly for breakthrough pain unresponsive to regional anesthesia plus acetaminophen. 2

If Opioid Therapy Is Necessary:

• Verify renal function before any opioid initiation. 2
• Reduce standard hydromorphone dose by 50-75% in patients with any renal impairment. 2
• Tramadol should be used with extreme caution starting at 12.5-25 mg every 6 hours, as it causes confusion in elderly patients and reduces seizure threshold. 7
• Tramadol is contraindicated in patients with seizure history or those taking SSRIs due to serotonin syndrome risk. 7
• Prescribe prophylactic laxative therapy (stool softener plus stimulant laxative) with any opioid use. 7

Special Considerations for Liver Disease

In patients with liver disease, acetaminophen should be used with extreme caution or avoided entirely, particularly when combined with opioid-acetaminophen preparations. 1

• The FDA limits acetaminophen in prescription combination products to 325 mg per dosage unit due to liver toxicity concerns. 1
• NSAIDs should be discontinued if liver function studies increase 3 times the upper limit of normal. 1

Special Considerations for Stomach Ulcers

Patients with history of peptic ulcer disease have a greater than 10-fold increased risk for GI bleeding with NSAIDs and should avoid them entirely. 5

• If NSAIDs must be used, selective COX-2 inhibitors have lower incidence of GI side effects but do not reduce renal toxicity. 1
• Proton pump inhibitors, H2 antagonists, or misoprostol are required for gastroprotection. 1

Multimodal Strategy and Timing

Surgery should occur within 48 hours of injury with adequate preoperative pain relief to reduce mortality and morbidity. 1, 2

• Orthogeriatric comanagement improves functional outcomes and reduces length of stay and mortality in elderly fracture patients. 1, 2
• Adequate analgesia prevents delirium, which occurs in 25% of hip fracture patients and interrupts rehabilitation. 2