What is the appropriate pain management for a 94-year-old female patient with impaired renal function (GFR of 54), normal creatinine levels, and an allergy to acetaminophen (Tylenol), who typically takes ibuprofen at home and presents with difficulty walking and a recent fall?

From the Guidelines

I strongly advise against administering ibuprofen to this 94-year-old female patient due to her heart failure and renal dysfunction, as NSAIDs can increase fluid retention and worsen HF, and instead recommend considering alternative pain management options such as paracetamol or topical NSAIDs, if not contraindicated by her allergy to Tylenol, or opioids with a safer metabolic profile like methadone, buprenorphine, or fentanyl for severe pain. Given her age, GFR of 54, and normal creatinine, it's crucial to prioritize her renal function and avoid potential exacerbation of HF. The patient's allergy to Tylenol (acetaminophen) complicates the situation, but according to the study by 1, paracetamol appears to be safe in HF, although this may not be an option for her. Topical NSAIDs might be considered, but their safety in HF patients has not been studied, as noted in the same study 1. For chronic non-cancer pain, non-pharmacologic and non-opioid pharmacologic therapy are preferred, and if opioids are necessary, they should be used in the lowest dose for the shortest duration, with consideration of safer options like methadone, buprenorphine, or fentanyl in patients with severely impaired renal function, as suggested by 1.

Some key points to consider in her pain management include:

• Avoiding NSAIDs due to the risk of worsening HF and renal strain
• Considering alternative pain management options that are safer for her renal function and HF status
• Monitoring her closely for signs of fluid retention, changes in renal function, and potential side effects of any prescribed medication
• Working on addressing the underlying cause of her fall and mobility issues to minimize the need for pain medication
• potentially consulting with pain management for alternative approaches that avoid both NSAIDs and acetaminophen, given her complex medical history and allergy to Tylenol.

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. Renal Effects Long-term administration of NSAIDs has resulted in renal papillary necrosis and other renal injury. Renal toxicity has also been seen in patients in whom renal prostaglandins have a compensatory role in the maintenance of renal perfusion In these patients, administration of a NSAID may cause a dose-dependent reduction in prostaglandin formation and, secondarily, in renal blood flow, which may precipitate overt renal decompensation. Patients at greatest risk of this reaction are those with impaired renal function, heart failure, liver dysfunction, those taking diuretics and ACE inhibitors, and the elderly

The patient has a GFR of 54, which indicates impaired renal function. Given this, ibuprofen tablets are not recommended due to the risk of renal toxicity and worsening renal function 2. Close monitoring of renal function would be necessary if ibuprofen therapy is initiated, but it's best to avoid use in this patient with impaired renal function.

• Key considerations:
  • Impaired renal function (GFR of 54)
  • Risk of renal toxicity and worsening renal function
  • Need for close monitoring of renal function if ibuprofen is used
• Recommendation: Avoid use of ibuprofen tablets in this patient due to impaired renal function 2.

From the Research

Patient's Condition

The patient is a 94-year-old female experiencing fall and difficulty walking, with a request for pain management. Her attending physician is Miller. The patient typically takes ibuprofen at home, has a GFR of 54, and normal creatinine levels, but is allergic to Tylenol.

Considerations for Pain Management

• The patient's allergy to Tylenol (acetaminophen) is a significant consideration, as it is often a first-line treatment for pain management 3.
• The patient's GFR of 54 indicates impaired renal function, which may affect the choice of pain medication 4.
• Ibuprofen, the patient's typical pain medication, is an NSAID that can be nephrotoxic, especially in patients with pre-existing renal impairment 5, 6, 7.

Alternative Pain Management Options

• Celecoxib, a structurally distinct NSAID, may be an option for pain management under close surveillance, as it has been shown to be safe in patients with a history of nephrotic syndrome associated with NSAID use 5.
• Opioids, such as tramadol, hydromorphone, and oxycodone, can be used with caution and close monitoring in patients with renal impairment 4.
• However, the use of acetaminophen, even in patients with renal impairment, has been associated with an increased risk of renal impairment 7, and its use should be approached with caution.

Important Considerations

• The patient's renal function and potential for nephrotoxicity should be closely monitored when selecting a pain management regimen 4, 6, 7.
• The patient's allergy to Tylenol and history of ibuprofen use should be taken into account when choosing an alternative pain medication 3.