N511 Module 6 assignment: Shadow Health reflection essay on pain management prescribing, a full sample

The Third Drug in the Triple Whammy: Reflecting on Pain Management for a 71-Year-Old With Knee Osteoarthritis and Reduced Kidney Function

Student Name

Master of Science in Nursing Program, Aspen University

N511: Advanced Pharmacology

Instructor Name

Month Day, Year

The Third Drug in the Triple Whammy: Reflecting on Pain Management for a 71-Year-Old With Knee Osteoarthritis and Reduced Kidney Function

Pain management in older adults is often a problem of what the patient is already taking. This module's ShadowHealth pain exercise presented a virtual patient, described here as a composite, a 71-year-old retired librarian with knee osteoarthritis who had been taking ibuprofen 400 mg three times daily from the drugstore for four months. She also takes lisinopril and hydrochlorothiazide for hypertension, and her estimated glomerular filtration rate has fallen from 64 to 51 mL/min/1.73 m^2 over the past year. In what follows I look back at how I assessed her, then take the module's prompts one at a time.

Reflection and Selection Rationale

I assessed her pain well, using a numeric scale and asking how it limited walking and stairs, but I nearly accepted her ibuprofen as harmless because it was over the counter. The combination of an NSAID with an ACE inhibitor and a diuretic reduces kidney perfusion from three directions: the diuretic lowers volume, the ACE inhibitor dilates the efferent arteriole, and the NSAID blocks the prostaglandins that dilate the afferent arteriole. In a large nested case-control study, this triple combination was associated with a 31 percent higher rate of acute kidney injury, rising to 82 percent in the first 30 days of use (Lapi et al., 2013). Her falling filtration rate is the warning the combination was already giving.

I would stop the oral ibuprofen and start topical diclofenac 1% gel applied to the knee four times daily. The 2019 osteoarthritis guideline strongly recommends topical NSAIDs for knee osteoarthritis, and their systemic absorption is far lower than that of oral agents (Kolasinski et al., 2020). Scheduled acetaminophen, up to 3 g daily, can be added for additional relief. This plan also aligns with the Beers Criteria, which advise older adults to avoid chronic use of oral NSAIDs unless other options fail and to avoid them entirely when creatinine clearance is severely reduced, because of the risks of gastrointestinal bleeding, kidney injury, and worsening blood pressure (2023 American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Her blood pressure readings should be reviewed as well, since NSAIDs can blunt the effect of her antihypertensives and removing ibuprofen may lower them.

Alternatives, Monitoring, and Education

If topical therapy and acetaminophen are not enough, duloxetine is a conditionally recommended option, though it can cause nausea and dizziness and raises fall risk in older adults. Tramadol is conditionally recommended, but its serotonin effects, seizure risk, and potential for dependence make it a later choice, and the guideline recommends against other opioids for osteoarthritis (Kolasinski et al., 2020).

I would recheck her creatinine and potassium in two to four weeks to confirm that her kidney function recovers. She should understand that ibuprofen and naproxen are the same kind of drug even when sold under different names, that she should avoid them unless her prescriber approves, and that topical gel should not be applied under heat or to broken skin. The guideline strongly recommends exercise and, for those who are overweight, weight loss, and I would refer her to physical therapy for a strengthening program.

What I Learned

This exercise taught me to count over-the-counter drugs as part of the medication list and to check every analgesic against the patient's kidney function and other prescriptions. A safer pain plan for her is not weaker; it simply treats the knee without harming the kidneys.

References

2023 American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., ... Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology, 72(2), 220-233. https://doi.org/10.1002/art.41142

Lapi, F., Azoulay, L., Yin, H., Nessim, S. J., & Suissa, S. (2013). Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: Nested case-control study. BMJ, 346, Article e8525. https://doi.org/10.1136/bmj.e8525