NMA: Nonprescription Medicines Academy

Nonprescription Medicines Academy
QuEST Case Study
April 2010

WD is a 56-year-old white woman who approaches you (the pharmacist) with a package of ibuprofen 200 mg. “This helps with pain other than headaches, right?” she asks.

You respond by inquiring about the type of pain WD is trying to treat. “Oh, just regular aches and pains, you know? I’m getting older, and I figure this is something you just have to live with. But the pain gets bad sometimes and I could use a little something to help with that.”

1. Using the QuEST method, quickly and accurately assess WD.

In talking with WD, you discover that she is a hair stylist in a salon located in a nearby small town. Although she spends much of her time standing, she gets no formal exercise and little physical activity during the course of a typical day. For the past 4 or 5 months, WD has been experiencing pain primarily in her knees; the pain—which she describes as a mild to moderate, dull ache—is most noticeable when she is standing or especially when walking. WD also experiences stiffness in her knees upon awakening each morning, but the stiffness resolves with some movement. Taking a friend’s recommendation, WD recently purchased Osteo Bi-Flex (dietary supplement containing glucosamine 1,500 mg and chondroitin, among other ingredients). She states that she “took it for a few days” but “didn’t notice any difference” in her pain.

WD is visibly obese; you estimate her body mass index (BMI) to be 33 or 34.

PHM: Type 2 diabetes (4 months)
Hypertension (3 years)

Current medications: Lisinopril 10 mg PO once daily
Metformin 1,000 mg PO twice daily

Allergies: NKDA

You conclude that the likely cause of WD’s pain is recent-onset osteoarthritis.

2. Using the SCHOLAR-MAC method, classify the pertinent information presented in this case.

3. Using the QuEST method, establish is this patient is an appropriate self-care candidate. Provide a rationale.

WD does appear to be an appropriate candidate for self-treatment, because:

• She does not report any severe symptoms.
• She does not have symptoms that persist or return repeatedly.
• She is not seeking to self-treat as a way to avoid medical care. For suspected osteoarthritis, it is acceptable for WD to begin self-treating symptoms before receiving an official diagnosis.

However, you should advise WD to make an appointment with her primary care provider for a complete diagnostic work-up.

4.If this patient is a self-care candidate, suggest appropriate self-care strategies (nonprescription medication, alternative treatments, general care measures).

Clinical practice guidelines emphasize the initial use of acetaminophen for the control of mild to moderate pain in osteoarthritis, in doses not to exceed 4 g daily. Recommend that WD begin therapy with acetaminophen instead of the ibuprofen product she has selected (especially because ibuprofen could interact with the angiotensin-converting enzyme inhibitor that WD takes currently, causing an elevation in her blood pressure).

Pharmacologic agents are considered to be adjuncts to nonpharmacologic measures for the treatment of osteoarthritis. WD is likely to benefit most from regular aerobic activity (e.g., daily walking) and muscle-strengthening exercises, as well as weight loss. Applying ice or heat (or alternating between the two) is another potentially beneficial pain relief strategy.

There is some evidence that glucosamine sulfate 1,500 mg per day—alone or in combination with chondroitin sulfate 1,200 mg per day—can decrease pain and improve joint function in patients with osteoarthritis, particularly osteoarthritis of the knee. However, these agents must be taken daily (not on an as-needed basis), and benefits might not be apparent for 4 to 5 months.

5. If suggesting self-care strategies to this patient, list the information you will discuss with the patient regarding the recommended strategies.

Urge WD to make an appointment with her primary care provider soon for a complete diagnostic work-up.

Counseling points for acetaminophen:

• Take with full glass of water.
• Do not take more than a total of 4 g daily.
• Avoid alcohol.

Information about alternative and nonpharmacologic measures:

• Drug therapy is most effective when combined with nonpharmacologic measures.
• Consider working toward a goal of daily, 30-minute walks.
• Discuss possibility of strength training exercises with primary care provider.
• Consider weight loss to relieve stress on joints.
• It probably is acceptable to resume therapy with Osteo Bi-Flex if desired. However, the product must be taken daily for up to 4 to 5 months before evaluating benefits. WD also should be aware that glucosamine may affect blood glucose levels, although the evidence is conflicting.