What is an appropriate pain management regimen for a 60‑year‑old woman with multiple sclerosis who has sustained a second right ankle fracture and is not on chronic analgesics?

Pain Management for 60-Year-Old Female with MS and Second Ankle Fracture

Start scheduled acetaminophen 1000 mg every 6 hours, add scheduled ibuprofen 400-800 mg every 6-8 hours (after renal/GI screening), initiate gabapentin 300 mg three times daily, and reserve tramadol 50-100 mg every 6 hours as needed for breakthrough pain only. 1

Immediate Pre-Treatment Assessment

Before prescribing NSAIDs, you must evaluate the following:

• Renal function (BUN, creatinine, eGFR) – NSAIDs worsen compromised kidneys and are contraindicated if eGFR <30 mL/min 1
• Gastrointestinal history – At age 60, she has a 5-6-fold higher risk of GI bleeding; prior ulcer disease carries ~5% recurrent bleeding risk within 6 months 1
• Cardiovascular status – Screen for hypertension, coronary disease, or stroke as NSAIDs may exacerbate these conditions 1
• Hydration status – Dehydration amplifies nephrotoxicity 1
• Current medications – Concurrent anticoagulants raise GI bleeding risk 5-6-fold and represent a contraindication 1

Scheduled Foundation Regimen (Not PRN)

First-Line: Acetaminophen

• Acetaminophen 1000 mg every 6 hours (maximum 3000-4000 mg/day) on a fixed schedule – This provides baseline analgesia, is safe in renal disease, and should be given to all adults with acute moderate-to-severe pain 1

Second-Line: NSAID (If No Contraindications)

• Ibuprofen 400-800 mg every 6-8 hours (maximum 2400 mg/day) on a fixed schedule – Scheduled dosing prevents fluctuations between peak and trough serum levels 2, 1
• Alternative: Naproxen 500 mg twice daily if preferred 1
• Maximum duration: 5-10 days for acute fracture pain 1

Third-Line: Gabapentinoid

• Gabapentin 300 mg three times daily, titrated up to 900-3600 mg/day as tolerated – This is especially important given her MS, as it addresses both neuropathic pain components and reduces opioid requirements 1, 3, 4
• MS-specific rationale: Gabapentin is first-line for MS-related neuropathic pain including painful dysesthesias and is effective for both fracture pain and underlying MS pain syndromes 3, 4

Breakthrough Pain Only: Opioid Rescue

• Tramadol 50-100 mg every 6 hours PRN is the preferred first-line rescue opioid after the multimodal foundation is established 1
• Age-adjusted dosing: At age 60, reduce opioid doses by 20-25% (so tramadol 37.5-75 mg PRN) 2, 1
• If tramadol insufficient: Oxycodone 5-10 mg every 4-6 hours PRN, dose-reduced by 20-25% (so oxycodone 3.75-7.5 mg PRN) 2, 1

Regional Anesthesia Consideration

• Peripheral nerve block (ankle block) should be employed if anatomically feasible – This markedly lowers opioid consumption, pain scores, and hospital length of stay in trauma patients 2, 1
• The AnAnkle Trial demonstrated that ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine decreased pain in ankle fracture patients 2

Monitoring Requirements During NSAID Use

For NSAID courses >5-10 days, monitor every 3 months: 1, 5

• Blood pressure (NSAIDs raise systolic BP by ~5 mmHg on average)
• BUN and creatinine
• Liver enzymes
• CBC and fecal occult blood

Immediate NSAID Discontinuation Criteria

Stop NSAIDs immediately if: 1

• Doubling of BUN or creatinine
• New or worsening hypertension
• Signs of acute kidney injury (reduced urine output, rising creatinine)
• Any gastrointestinal bleeding
• Liver enzymes >3× upper limit of normal

MS-Specific Pain Considerations

• MS patients commonly experience multiple pain syndromes simultaneously – combinations of dysesthesias, headaches, back pain, and muscle/joint pain are frequent 3
• Neuropathic pain in MS responds poorly to opioids alone – multimodal therapy with gabapentinoids and antidepressants is more effective 2, 3, 4
• Recurrent fractures in MS suggest underlying osteoporosis or mobility issues – address fall prevention, bone health, and physical therapy alongside pain management 3, 6

Common Pitfalls to Avoid

• Do not use PRN dosing for acetaminophen and NSAIDs – scheduled administration prevents pain fluctuations and reduces total opioid consumption 2, 1
• Do not start opioids first – establish the multimodal foundation before adding opioid rescue 1
• Do not ignore age-based dose reductions – older trauma patients require fewer opioids (20-25% reduction per decade after age 55) without altering pain control 2, 1
• Do not continue NSAIDs beyond 5-10 days without reassessment – prolonged use increases GI/renal/cardiovascular risks 1
• Do not overlook gabapentin's dual benefit – it treats both fracture pain and underlying MS neuropathic pain 3, 4

Practical Implementation Algorithm

1. Screen for NSAID contraindications (renal, GI, cardiovascular, anticoagulation) 1
2. Start scheduled foundation:
   • Acetaminophen 1000 mg every 6 hours 1
   • Ibuprofen 400-800 mg every 6-8 hours (if no contraindications) 1, 7
   • Gabapentin 300 mg three times daily 1, 3
3. Consider ankle nerve block if available 2, 1
4. Reserve age-adjusted tramadol (37.5-75 mg PRN) for breakthrough pain 2, 1
5. Monitor labs at baseline and every 3 months if NSAIDs continue >10 days 1, 5
6. Discontinue NSAIDs after 5-10 days or immediately if safety thresholds met 1
7. Transition to gabapentin monotherapy for ongoing MS-related pain after fracture heals 3, 4