What alternative pain management options can be considered for a patient with leg pain post-hip fracture, including a neuropathic component, currently treated with pregabalin (50 mg orally twice daily), nortriptyline (10 mg at bedtime), duloxetine (90 mg daily), and oxycodone (10 mg every 4 hours as needed) to reduce reliance on opioids?

From the Guidelines

To optimize pain management for this patient with post-hip fracture leg pain with neuropathic components while reducing opioid reliance, I recommend increasing the pregabalin dose to 75-100 mg twice daily, as the current 50 mg twice daily may be suboptimal for neuropathic pain, as suggested by the most recent guidelines 1. The nortriptyline dose could be gradually increased to 25-50 mg at bedtime if tolerated, as 10 mg is often below the therapeutic range for pain management. Consider converting the prn oxycodone to a scheduled regimen with a long-acting formulation like oxycodone ER 10-20 mg twice daily to provide more consistent pain control. Topical options such as lidocaine 5% patches or diclofenac gel applied to the painful area could provide localized relief without systemic side effects. Non-pharmacological approaches including physical therapy, TENS units, and cognitive behavioral therapy should be incorporated into the treatment plan. The patient is already on multiple medications that work on different pain pathways (pregabalin for calcium channel modulation, nortriptyline and duloxetine for serotonin and norepinephrine reuptake inhibition), so optimizing these existing medications rather than adding new agents may be most appropriate. Careful monitoring for side effects such as sedation, dizziness, and anticholinergic effects is essential, especially with dose increases of pregabalin and nortriptyline in combination with other centrally-acting medications, as noted in previous studies 1.

Some key points to consider:

• The patient's current medication regimen includes pregabalin, nortriptyline, and duloxetine, which all have different mechanisms of action and can be optimized for better pain control.
• Increasing the pregabalin dose to 75-100 mg twice daily may help alleviate neuropathic pain, as it is a common dose range for this condition 1.
• Converting the prn oxycodone to a scheduled regimen with a long-acting formulation can provide more consistent pain control and reduce the risk of opioid dependence.
• Topical options and non-pharmacological approaches can provide additional relief without increasing the risk of systemic side effects.
• Careful monitoring of side effects is crucial, especially when combining multiple centrally-acting medications.

Overall, the goal is to optimize the patient's current medication regimen, reduce opioid reliance, and improve pain control while minimizing side effects, as recommended by the most recent guidelines 1.

From the FDA Drug Label

2.5 Management of Fibromyalgia in Adults The recommended dose of pregabalin for fibromyalgia is 300 to 450 mg/day. Begin dosing at 75 mg two times a day (150 mg/day). The dose may be increased to 150 mg two times a day (300 mg/day) within 1 week based on efficacy and tolerability Patients who do not experience sufficient benefit with 300 mg/day may be further increased to 225 mg two times a day (450 mg/day).

The patient is currently taking pregabalin 50 mg po bid, which is a lower dose than the recommended dose for managing neuropathic pain. Considering the patient's condition, the dose of pregabalin can be optimized by increasing it to 300 mg/day as recommended for neuropathic pain management.

• The patient's current dose of pregabalin is 100 mg/day, which can be increased to 300 mg/day.
• Additionally, the patient is taking duloxetine 90 mg daily, which can also be used to manage neuropathic pain.
• Nortriptyline 10 mg qhs is an antidepressant that can also be used to manage neuropathic pain, but its dose may need to be adjusted based on the patient's response.
• To reduce the patient's reliance on oxycodone, other non-opioid pain medications such as gabapentin or topical creams can be considered.
• It is essential to monitor the patient's response to these medications and adjust the doses accordingly to achieve optimal pain management while minimizing the risk of adverse effects 2.

From the Research

Current Medications and Potential Optimizations

• The patient is currently taking pregabalin 50 mg po bid, nortriptyline 10 mg qhs, duloxetine 90 mg daily, and prn oxycodone 10 mg every 4 hours while awake.
• Considering the patient's neuropathic pain component, the current medications may not be optimized for pain relief, as evidenced by the frequent use of oxycodone 3.
• The combination of pregabalin and duloxetine may have a synergistic effect on mechanical allodynia, but not on neuroma pain, suggesting that alternative or additional medications may be necessary 3.

Alternative and Add-on Medications

• Gabapentin, an α2δ ligand similar to pregabalin, may be considered as an add-on medication, as combination therapy with gabapentin and pregabalin has been shown to have a synergistic effect in pain control without significant pharmacokinetic interactions 4.
• Desipramine, a tricyclic antidepressant, may be considered as an alternative or add-on medication, as it has been shown to be cost-effective for the treatment of painful diabetic neuropathy 5.
• Other non-pharmacologic strategies, such as acupuncture, massage therapy, and mind-body behavioral interventions, may also be considered as part of a comprehensive pain management plan 6.

Opioid Reduction Strategies

• The patient's frequent use of oxycodone suggests a need for alternative pain management strategies to reduce reliance on opioids.
• Combination therapy with non-opioid medications, such as pregabalin, gabapentin, and duloxetine, may help reduce the need for oxycodone 3, 4.
• Non-pharmacologic strategies, such as those mentioned earlier, may also help reduce the patient's reliance on opioids 6.