A case of cauliflower ears
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A Case of Cauliflower Ears. Hilary Rowe, BScPharm VIHA Pharmacy Resident 2009-10 Pain Clinic Rotation. Outline. Objectives Background Patient Case Clinical Question Review of Evidence Recommendation Monitoring. Objectives.

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A Case of Cauliflower Ears

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A Case of Cauliflower Ears

Hilary Rowe, BScPharm

VIHA Pharmacy Resident 2009-10

Pain Clinic Rotation


Outline

  • Objectives

  • Background

  • Patient Case

  • Clinical Question

  • Review of Evidence

  • Recommendation

  • Monitoring


Objectives

  • Describe 1 way inflammation destroys cartilage in relapsing polychondritis (RP)

  • Name 3 risk factors for addiction in a pain patient

  • Be familiar with the evidence of disease modifying agents in RP


Relapsing Polychondritis

  • Destruction of cartilage and replacement with fibrous tissue

  • Autoantibodies to type II, IX, XI collagen causes inflammatory infiltration

  • Produce Th1 cytokines (TNF-α) by T-cell clones reactive to Type II collagen

  • Lysosomal enzyme release eventually results in destruction of the cartilage


Diagnostic Criteria

Presence of 3 or more:

  • Recurrent chondritis both auricles

  • Non-erosive inflammatory polyarthritis

  • Nasal chondritis

  • Ocular inflammation

  • Respiratory tract chondritis

  • Cochlear &/or vestibular dysfunction


Symptoms


Treatment

?

Methotrexate, Colchicine,

Dapsone, Hydroxychloroquine

Treat inflammation-Prednisone

Treat pain-NSAIDS

Diagnosis


Mrs. MJ

  • ID: 40 yo female, ht 155cm, wt 62kg

  • CC: Acute decline in functioning with widespread pain and stiffness in joints

  • HPI Nov 2009:Current RP flare of longest duration; walking this summer and now in motorized wheel chair since September

  • RP diagnosed Aug 2009, polyarthritis since 2005


Mrs. MJ

  • PMHx:Transposition of ureters 1983- Recurrent UTI’s (prior to surgery 8-9/year, after surgery 1-2/year)

  • Allergies: Lactose (hives & difficulty breathing)


Mrs. MJ

  • Social & Family Hx:

    • Lives with husband & two teenagers

    • Prior to attack was running an event planning business

    • Both parents were alcoholics

  • Discharge Plan from Pain Clinic:

    • Improve pain control & function


Medical Problem List

Active:

  • Prolonged flare of RP

  • Pain

  • Constipation

    Chronic:

  • Depression • Osteopenia • RP

  • Graves disease • Pain


Review of Systems


  • Score is 5:

  • 3 points family history

  • 1 point age

  • 1 point depression

  • Other factors:

  • Drug seeking

  • Altering routes

  • Running out early

  • Rx forgery

  • Stealing

  • ↑ dose with no change in disease state


Review of Systems


Review of Systems


Review of Systems


Review of Systems


Review of Systems


Pain History

Paroxysmal attacks:

  • Left side more affected then right

  • Described: red-hot poker stabbing and digging into her

  • 20/10 causing her to sob, occurs with flares

  • What makes it better-? more medication

  • What makes it worse- Nothing


Pain History

Baseline aches:

  • Widespread: Nose, chest, sternum, jaw, elbows, back, shoulders, wrists, hands, hips, ankles

  • Described: ache

  • What makes it better-baths, medication

  • What makes it worse- > 300-400 steps per a day


DRPs

  • MJ has a prolonged polychondritis flare and is experiencing additional pain not controlled by her current therapies

  • MJ is experiencing constipation secondary to narcotics and immobility and could benefit from a regular bowel routine


DRPs

  • MJ has a prolonged flare of polychondritis and could potentially benefit from re-evaluation of her disease modifying agents


Question

  • Are there any disease-modifying therapies that might be helpful for Mrs. MJ’s prolonged flare of relapsing polychondritis, taking into consideration the medications she has already tried?


Therapeutic Options

  • No change in therapy

  • Infliximab

  • Rituximab

  • Azathioprine

  • Cyclophosphamide


Clinical Question


Search Strategy

  • PubMed, Embase, Google

  • Search terms:

    • Relapsing polychondritis

    • Disease modifying agents

    • Autoimmune diseases

  • Found

    • 3 case reports, 1 retrospective review


Leroux et al. Arthritis & Rheumatism 2009


Leroux et al. Arthritis & Rheumatism 2009


Leroux et al. Arthritis & Rheumatism 2009

  • Results:

  • 2 partial remissions

  • 4 stable

  • 3 worsened

    • 2 added new immunosuppressants

    • 2 increased steroid dose

    • 6 benefitted- at 12 months 2 remained stable & 4 were worse


Leroux et al. Arthritis & Rheumatism 2009


Marie et al. Rheumatology 2009


Buonuomo et al. Rheumatol Int 2009


Richez et al. Rheumatol Int 2009


Goals of Therapy

Patients Goals

  • Improve pain control

  • Increase mobility and ADL

  • Return to work

    Team Goals

  • Improve pain control

  • Increase mobility and ADL

  • Slow progression of disease

  • Decrease morbidity & mortality

  • Minimize adverse drug events


Recommendation

  • No definitive evidence to support suggesting a disease-modifying agent

  • Risks and benefits of infliximab should be discussed with patient

  • Patient should make an informed decision to start therapy


Recommendation

  • Improve pain control

    • Discontinue Codeine Contin

    • Start Morphine 30mg long acting q 12h

    • Start Morphine IR 5mg prn for breakthrough pain


Recommendation

  • Codeine Contin ineffective pain 20/10, poor sleep, dose above ceiling effect of 400mg/day

  • Morphine is effective for breakthrough pain

  • Morphine less potential for abuse then hydromorphone and oxycodone

  • SR formulation less potential for abuse


Monitoring


Monitoring


Follow Up- Feb 2010

  • Patient switched from Codeine Contin to Morphine (↓ IR 2 daily to 2-3 nights/wk)

  • Currently ↓ prednisone dose

  • Patient wanted to trial dapsone & colchicine 1st (DMARD was not started)

  • Patient now considering DMARD option

  • Constipation improving


Questions?


References

  • Kahan M, Srivastava A, Wilson L et al. Misuse of and dependence on opioids: study of chronic pain patients. Canadian Family Physician 2006;52:1081-87.

  • Marie I, Lahaxe L, Josse S, Levesque H. Sustained response to infliximab in a patient with relapsing polychondritis with aortic involvement. Rheumatology 2009 Oct;48(10):1328-33.

  • Leroux G, Costedoat-Chalumeau N, Brihaye B, et al. Treatment of relapsing polychondritis with rituximab: a retrospective study of nine patients. Arthritis Rheumatology 2009 May 15;61(5):577-82.

  • Buonuomo PS, Bracaglia C, Campana A, et al. Relapsing polychondritis: new therapeutic strategies with biological agents. Rheumatology International. 2009 Aug 15. [Epub ahead of print].

  • RichezC, Dumoulin X, Schaeverbeke T. Successful treatment of relapsing polychondritis with infliximab. Clinical and Experimental Rheumatology 2004;22:629-31.

  • PorroGB, Lazzaroni M, Imbesi V et al. Efficacy of pantoprazole in the prevention of peptic ulcers, induced by non-steroidal anti-inflammatory drugs: a prospective, placebo-controlled, double-blind, parallel-group study. Digestive and Liver Disease 2000 April; 32(3): 201-208.


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