OTC Case Studies: Pain Management

Case 1—Cramp Relief

DK is an 18-year-old woman who approaches the pharmacist at her college’s student health center for a medication to alleviate cramps. She reports experiencing cramping abdominal pain, nausea, fatigue, and headache for the pastday. Upon questioning, you identify that DK is currently menstruating, not allergic to medication, not sexually active, and has no chronic medical conditions. She reports recently starting to smoke cigarettes, a habit that she attributes to stress. Although DK used ibuprofen when she experienced these symptoms previously, it worsened her upset stomach and did not relieve the pain. Counsel DK on strategies for improving the efficacy and safe use of ibuprofen and describe other nonpharmacologic interventions you could recommend for her symptoms.

Answer

DK is likely experiencing primary dysmenorrhea. Primary dysmenorrhea is an idiopathic condition thought to be related to the release of prostaglandins and leukotrienes, inflammatory mediators that are associated with uterine vasoconstriction, ischemia, and pain during menstruation. ¹ Although pain is generally localized to the lower abdominal area, systemic symptoms related to prostaglandin release, including nausea, vomiting, diarrhea, andheadache, may occur.2 OTC analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, are the most commonly used treatments. DK reports experiencing adverse gastrointestinal (GI) side effects secondary to the use of ibuprofen, but NSAIDs such as ibuprofen are the agents with the best evidence to support their use for treating menstrual pain. At maximum daily doses, acetaminophen has been shown to be less effective than ibuprofen in clinical trials for menstrual pain relief,3 and doses up to 1000 mg 4 times per day may be necessary for adequate pain relief. Recommend that DK continues to use ibuprofen 200 to 400 mg every 4 to 6 hours as needed for pain (up to 1200 mg per day), but she should take it with food to minimize GI upset. DK should take the medicationon a scheduled rather than an as-needed basis for the first 24 to 48 hours of menstruation, when levels of inflammatory mediators are the highest. Smoking cessation may help improve DK’s symptoms, as smoking has been associated with more painful menstruation.⁴ The use of localized heat applied to the affected area, by either a heating pad or abdominal heat patch, has also been shown to relieve pain and cramping associated with menstruation. The application of heat has a faster onset of action than oral analgesics and may also augment their effects. Counsel DK on the importance of adequate rest and routine physical activity, which may also help to minimize her symptoms.

Case 2—Commuter Headache

PJ is a 52-year-old man looking for arecommendation for a headache medicine. PJ massages his temples, where he describes experiencing a constricting, band-like pain around his head. He experienced similar headache pain approximately 2 times per week for the past few weeks, which he attributes to the stress of starting a new job in a nearby city and to his long commute. He denies allergies to medications and reports taking lisinopril/ hydrochlorothiazide 20 mg/25 mg daily for hypertension and simvastatin 40 mg daily for hypercholesterolemia. Based on the type of headache PJ is likely experiencing, identify an appropriate analgesic medication for alleviating his pain.

Answer

PJ is likely experiencing episodic tensiontype headaches, with characteristic bilateral,band-like pain that extends over the top of the head and toward the base of the skull. Tension-type headaches can be associated with stress, anxiety, depression, and other emotional stimuli.⁵ OTC analgesics, including NSAIDs, salicylates, and acetaminophen, are effective at mitigating these types of episodic headaches. In the case of PJ, any of these agents would be reasonable recommendations for alleviating his pain; however, acetaminophen may carry a more favorable safety profile, given the presence of cardiovascular disease risk factors in his case (eg, hyperlipidemia, hypertension). According to the American Heart Association, patients who are at high risk for cardiovascular disease should avoid NSAIDs if possible, due to an increased risk of myocardial infarction, stroke, heart failure, and hypertension.⁶ The selection of a NSAID may increase the risk of PJ experiencing adverse effects on renal function, based on his concomitant use of a diuretic and angiotensin-converting enzyme inhibitor combination. Recommend the use of acetaminophen 500 to 1000 mg every 4 to 6 hours as needed (up to 4000 mg per day). Remind PJ to limit alcohol consumption to prevent acetaminophen-induced hepatic damage.

References:

1. What Are Menstrual Cramps? What Causes Menstrual Cramps? What Are Period Pains? Journal of Anesthesiology Clinical Pharmacology. Available at: www.joacp.org/index.php?option=com_content&view=article&id=249:what-are-menstrual-cramps-what-causes-menstrual-cramps-what-are-period-pains&catid=1. Accessed July 12, 2010.

2. Shimp LA. Disorders Related to Menstruation. In: Berardi R, Ferreri S, Hume A, et al., eds. Handbook of Nonprescription Drugs, 16th ed. Washington DC: The American Pharmacists Association; 2009. 138-145.

3. Dawood MY, Khan-Dawood FS. Clinical efficacy and differential inhibition of menstrual fluid prostaglandin F2a in a randomized, double-blind, crossover treatment with placebo, acetaminophen, and ibuprofen in primary dysmenorrhea. Am J Obstet Gynecol 2007;196:35e1-e5.

4. Durain D. Primary dysmenorrhea: assessment and management update. J Midwifery Women’s Health 2004;49:520-8.

5. Diamond S. Tension-type headache. Clinical Cornerstone 1999;1:33-44.

6. Antman EM, Bennett JS, Daugherty A, et al. Use of Nonsteroidal Antiinflammatory Drugs: An Update for Clinicians: A Scientific Statement From the American Heart Association. Circulation 2007;115:1634-1642.

Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Patel is a clinical pharmacist in North Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.