What is the appropriate pain management for a 94-year-old female patient with impaired renal function (GFR of 54), presenting with difficulty walking and a history of falls, who typically takes Ibuprofen at home and is allergic to Tylenol (Acetaminophen)?

From the Guidelines

I strongly recommend avoiding NSAIDs, such as ibuprofen, in this 94-year-old female patient with a GFR of 54, due to the potential risk of acute kidney injury and gastrointestinal complications, as highlighted in the 2023 WSES guidelines on the management of trauma in elderly and frail patients 1. Instead, consider alternative pain management options that are safer for elderly patients with renal impairment. Given the patient's allergy to Tylenol (acetaminophen), it is essential to explore other alternatives. For pain management, consider using opioids, but with caution, as they are associated with serious cardiovascular events, acute dyspeptic syndrome, and an increased risk of respiratory failure, as noted in the study 1. However, opioids may be necessary for moderate to severe pain, and their use should be carefully monitored. It is crucial to select a pain measurement scale that is appropriate for the patient's ability to read, hear, and understand, such as the numeric rating scale (NRS), verbal descriptor scale (VDS), faces pain scale (FPS), or visual analogue scale (VAS), as described in the study 1. In this case, since the patient is experiencing difficulty walking and has a history of falls, it is essential to minimize sedating medications and consider a physical therapy evaluation to address her mobility issues. Regular monitoring of her renal function and overall health status is necessary to ensure the safe use of any pain management medication. Additionally, consider consulting with pain management specialists to explore alternative options that prioritize the patient's safety and quality of life. Some key points to consider when managing pain in elderly patients include:

• Using pain assessment tools that are suitable for the patient's cognitive and communication abilities
• Selecting medications that have minimal side effects and are tailored to the patient's clinical features and needs
• Monitoring renal function and overall health status regularly
• Minimizing sedating medications to reduce the risk of falls and other adverse events
• Considering alternative pain management options, such as physical therapy and non-pharmacological interventions, to prioritize the patient's quality of life and safety.

From the FDA Drug Label

Advanced Renal Disease No information is available from controlled clinical studies regarding the use of ibuprofen tablets in patients with advanced renal disease. Therefore, treatment with ibuprofen tablets is not recommended in these patients with advanced renal disease If ibuprofen tablets therapy must be initiated, close monitoring of the patients renal function is advisable.

• The patient has a GFR of 54, which may indicate impaired renal function.
• The FDA drug label recommends close monitoring of the patient's renal function if ibuprofen tablets are used in patients with impaired renal function 2.
• Given the patient's age (94 years) and impaired renal function, it is recommended to exercise caution when using ibuprofen tablets.
• The patient's renal function should be closely monitored if ibuprofen tablets are prescribed.
• Consider alternative therapies that do not involve NSAIDs, especially in high-risk patients like the elderly or those with impaired renal function 2.

From the Research

Patient's Condition and Request

The patient is a 94-year-old female experiencing fall and difficulty walking, with a request for pain management. Her current medication includes ibuprofen, which she typically takes at home. However, her GFR is 54, and she is allergic to Tylenol.

Considerations for Pain Management

• The patient's kidney function is a crucial consideration when selecting a pain management option. According to 3, nonopioid analgesics, including acetaminophen, may be considered for pain management in patients with kidney disease, but with careful dose considerations.
• However, a study by 4 found that acetaminophen use is associated with an increased risk of renal impairment, which may be a concern for this patient.
• NSAIDs, such as ibuprofen, may be used in CKD and ESKD for short durations with careful monitoring, as stated in 3.
• Opioid use should be minimized and reserved for patients who have failed other therapies, according to 3.

Alternative Pain Management Options

• Topical NSAIDs may be recommended for non-low back, musculoskeletal injuries, as stated in 5.
• Adjunctive medications, such as muscle relaxants, may be added as appropriate for specific conditions, according to 5.
• A study by 6 found that oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen alone for patients with acute musculoskeletal pain refractory to oral ibuprofen, but with more medication-related adverse events.

Potential Drug Interactions

• The patient's use of ibuprofen and potential interactions with other medications should be considered, as stated in 7.
• The ability of selective serotonin reuptake inhibitors to inhibit the analgesic activity of tramadol and codeine should be noted, according to 7.