Scope of Practice Limitation: Lupus Pain Management Beyond Psychiatric NP Authority
As a psychiatric nurse practitioner, you should not independently prescribe medications specifically for lupus pain, as this falls outside standard psychiatric NP scope of practice and requires rheumatology or primary care oversight. However, you can optimize her existing psychiatric medications that may provide secondary analgesic benefits and coordinate care with her rheumatology team.
What You Can Do Within Your Scope
Optimize Existing Gabapentin for Neuropathic Pain Component
- Her current gabapentin 200 mg TID (600 mg/day total) is substantially below therapeutic dosing for pain management 1, 2
- Gabapentin can be titrated up to 900-3600 mg/day in divided doses for neuropathic pain, with dose increments of 50-100% every few days 1
- This is appropriate within psychiatric NP scope when addressing chronic pain syndrome (one of her documented conditions) 2
- Start by increasing to 300 mg TID (900 mg/day), then titrate weekly based on response and tolerability 1
- Slower titration is warranted given her age (77 years) and medical complexity 1
Consider Antidepressant with Analgesic Properties
- Duloxetine 30-60 mg daily would be appropriate for both her mood disorder and chronic pain syndrome 1
- SNRIs like duloxetine provide effective analgesia for chronic pain conditions, often at lower dosages than needed for depression treatment 1
- This addresses two of her documented conditions simultaneously: unspecified mood disorder and chronic pain syndrome 1
- Duloxetine is FDA-approved for chronic musculoskeletal pain and has evidence in neuropathic pain conditions 1
Avoid Tricyclic Antidepressants in This Patient
- While amitriptyline or nortriptyline would typically be considered for chronic pain (starting 10-25 mg nightly, titrating to 50-150 mg) 1, they are contraindicated in this 77-year-old with dementia and delirium 1
- Anticholinergic adverse effects (sedation, urinary hesitancy, confusion) are particularly problematic in elderly patients with cognitive impairment 1
Critical Coordination Required
The Rheumatology Team Must Manage Lupus-Specific Treatment
- NSAIDs should be used judiciously for limited periods in SLE patients at low risk for complications 1
- However, this patient has aspirin allergy and is 77 years old with multiple comorbidities, making NSAIDs particularly high-risk 3
- NSAIDs can induce acute renal failure in lupus nephritis patients, cause sodium retention, reduce GFR, and have increased cutaneous/allergic reactions in SLE 3
Her Current Prednisone 5 mg Daily is Appropriate Baseline
- She is already on low-dose glucocorticoid therapy (5 mg daily), which is standard for SLE maintenance 1
- Glucocorticoids combined with immunosuppressive agents are the foundation for SLE treatment, not psychiatric medications 1
Acetaminophen Optimization is Already Maximal
- She is currently on acetaminophen 650 mg ER BID plus 500 mg Q6H PRN, with explicit instructions not to exceed 3g/24h [@patient medications@]
- This is appropriate maximum dosing given her age and need to avoid hepatotoxicity 1
- Acetaminophen >3-4 grams/day can be hepatotoxic, with lower thresholds in elderly patients 1
What You Should NOT Do
Do Not Prescribe Topical Agents for Lupus Pain
- While topical lidocaine patches (5%) or compounded amitriptyline-ketamine have evidence for localized neuropathic pain 1, lupus pain is typically systemic and inflammatory, not localized neuropathic pain 1
- These would be inappropriate for systemic lupus-related musculoskeletal pain 1
Do Not Adjust Her Opioid Therapy
- She has hydrocodone-acetaminophen 5-325 mg (½ tablet Q8H PRN) prescribed by another provider [@patient medications@]
- Opioid management for chronic pain in a 77-year-old with dementia, delirium, and conversion disorder requires pain medicine or palliative care expertise, not psychiatric NP management 1
Avoid Carbamazepine Despite Anticonvulsant Properties
- While carbamazepine has analgesic properties for neuropathic pain 1, it can induce drug-induced lupus and should be avoided in SLE patients 4, 5
- Case reports document carbamazepine-induced systemic lupus with persistent ANA antibodies for years after discontinuation 5
Recommended Action Plan
1. Increase gabapentin to 300 mg TID (900 mg/day) immediately, with plan to titrate to 1200-1800 mg/day over 2-4 weeks based on response 1, 2
2. Consider adding duloxetine 30 mg daily, increasing to 60 mg after one week if tolerated 1
3. Document that you are treating her chronic pain syndrome and mood disorder (both documented conditions), not specifically prescribing for lupus [@patient conditions@]
4. Communicate with her rheumatology team (or refer if she lacks one) regarding inadequate lupus pain control and need for disease-modifying therapy optimization 1
5. Ensure she has palliative care involvement given her DNR status and multiple serious conditions [@patient conditions@]
Critical Safety Considerations
Monitor for Polypharmacy Risks
- She is already on diazepam 2.5 mg Q4H while awake, quetiapine 25 mg QHS, and hydrocodone PRN [@patient medications@]
- Adding sedating medications (gabapentin at higher doses, duloxetine) increases fall risk in this 77-year-old with dementia 1
- The combination of benzodiazepines, antipsychotics, opioids, and gabapentin substantially increases delirium risk 1
Infection Surveillance is Critical
- SLE patients on immunosuppression (she's on prednisone) have increased infection risk, which is a major cause of morbidity and mortality 1, 6
- Her current UTI on cefdinir requires completion and monitoring [@patient medications@, 6]
- Constitutional symptoms could represent infection rather than lupus flare 6, 7