Pain management combination therapy

This is another area primed for active pharmacy involvement as many of these patients are in nursing homes. These patients are usually undergoing monthly medication reviews by pharmacists who can suggest appropriate dosages and combinations for the management of pain. An article by Shimp estimated that 45-80% of nursing home residents and 20-50% of elderly in the community suffer from pain. This article discusses appropriate selection of therapy and the risks for adverse effects. 

While being devoid of myelosuppressive effects, tretinoin therapy is associated with headache, skin and mucous membrane reactions, bone pain, nausea, and the retinoic acid syndrome. When tretinoin is started, rapid onset of differentiation of promyelocytes occurs, which can lead to leukocytosis and/or retinoic acid syndrome. The retinoic acid syndrome (fever, respiratory distress, interstitial pulmonary infiltrates, pleural effusions, and weight gain) is now referred to as the APL differentiation syndrome or APL hyperleukocytosis syndrome, because it has been associated with other treatment modalities in the management of APL. Among tretinoin-treated patients, this syndrome has been fatal in 5% to 29% of cases. A combination of chemotherapy with tretinoin induction decreases the incidence of retinoic acid syndrome, and rapid initiation of dex-amethasone 10 mg (0.2 mg/kg per dose in children) twice daily for 3 days upon development of symptoms decreases associated mortality. 

Initial management should include a trial of anti-inflammatory medication, ankle bracing, and physical therapy. Many diagnostic tests are available. Sobel et al. popularized the peroneal tunnel compression test for longitudinal peroneus brevis tendon tears. This maneuver combines dorsiflexion and eversion of the foot and ankle with manual pressure on the peroneal tendons to elicit a painful response." Plain radiographs may demonstrate bony avulsions of the superior retinaculum or fractures. 

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