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The patient is presented to the hospital with hip pain that, according to him, was caused by a workplace injury. The pain has persisted for seven years now, and after multiple diagnostic tests and examinations, it was discovered that his right hip joint was 75% torn. When referred to a surgeon, the patient was met with rejection because he was too young to undergo complete hip replacement. Since then, the man has been suffering from a cluster of symptoms including extreme cooling and cramping, which made neurologists believe that he has complex regional pain syndrome (CRPS). According to the patient, his condition is hurting his mental health and has also ruined his relationship with his fiancee. Despite the psychological strain, the patient is alert, behaves appropriately, can communicate, and denies any hallucinations, paranoia, depression, or suicidal ideation.
The first decision that the nurse has made to relieve CRPS symptoms is to prescribe amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg. Oral administration of amitriptyline reaches a bioavailability of 30-60% and is widely distributed through the human body, binding to tissue and plasma proteins (Kondratenko et al., 2019). The plasma half-life of the medication lies between 10 and 28 hours and 16 and 80 hours for its metabolite, nortriptyline (Kondratenko et al., 2019). When used for neuropathic pain, amitriptyline acts as a local anesthetic due to its ability to block voltage-gated sodium channels.
After the administration of amitriptyline, the patient reported that his pain level dropped from nine out of ten to six out of ten. Among other positive results is a reduction in toe cramping that used to cause a lot of discomfort for the patient. These outcomes are consistent with existing research: for instance, Brown et al. (2016) show that when used for six weeks, amitriptyline led to an improvement in pain symptoms. As reported by van den Driest et al. (2017) sleepiness is a common side effect of amitriptyline, which is something that the patient is experiencing. In summation, the first decision led to satisfactory results, though the pain levels are manageable but not exactly low.
Because the pain levels are far from ideal and the patient complaints about morning grogginess, the nurse decides to work toward 200mg of amitriptyline daily. The patient is advised to take the medication one hour early every night to avoid the side effects. As a result, he reports reduced pain levels, improved mobility, and even a return to dating life. Moore et al. (2015) reveal that adverse events associated with the use of amitriptyline wane after two or three weeks while the benefits become more prominent.
However, alongside positive changes, the patient is frustrated with weight gain. For this reason, the third decision includes not only Elavil but also a referral to a nutrition coach who could help him with dietary habits. Existing research suggests that diet plays a crucial role in preserving and improving mental health. Disordered eating may lead to an onset of mental disorders or the deterioration of those with which a person is already diagnosed. For instance, Firth et al. (2019) confirm that dietary interventions are beneficial for treating both depression and anxiety. Therefore, eating healthy will help the patient to make sure that he keeps his psychological state in check and acts proactively toward his goals.
References
Brown, S., Johnston, B., Amaria, K., Watkins, J., Campbell, F., Pehora, C., & McGrath, P. (2016). A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children. Scandinavian Journal of Pain, 13, 156-163.
Firth, J., Marx, W., Dash, S., Carney, R., Teasdale, S. B., Solmi, M., Stubbs, B., Schuch, F. B., Carvalho, A. F., Jacka, F., & Sarris, J. (2019). The effects of dietary improvement on symptoms of depression and anxiety: a meta-analysis of randomized controlled trials. Psychosomatic Medicine, 81(3), 265–280.
Kondratenko, S. N., Savelyeva, M. I., Kukes, V. G., Shikh, E. V., & Gneushev, E. T. (2019). Experimental and Clinical Pharmacokinetics of Fluoxetine and Amitriptyline: Comparative Analysis and Possible Methods of Extrapolation. Bulletin of experimental biology and medicine, 167(3), 356-362.
Moore, R. A., Derry, S., Aldington, D., Cole, P., & Wiffen, P. J. (2015). Amitriptyline for neuropathic pain in adults. The Cochrane database of systematic reviews, 2015(7), CD008242. Web.
van den Driest, J. J., Bierma-Zeinstra, S. M., Bindels, P. J., & Schiphof, D. (2017). Amitriptyline for musculoskeletal complaints: a systematic review. Family Practice, 34(2), 138-146.
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