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

A Case of Cauliflower Ears

Hilary Rowe, BScPharm

VIHA Pharmacy Resident 2009-10

Pain Clinic Rotation


Outline

Outline

  • Objectives

  • Background

  • Patient Case

  • Clinical Question

  • Review of Evidence

  • Recommendation

  • Monitoring


Objectives

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

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

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

Symptoms


Treatment

Treatment

?

Methotrexate, Colchicine,

Dapsone, Hydroxychloroquine

Treat inflammation-Prednisone

Treat pain-NSAIDS

Diagnosis


Mrs mj

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 mj1

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 mj2

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

Medical Problem List

Active:

  • Prolonged flare of RP

  • Pain

  • Constipation

    Chronic:

  • Depression • Osteopenia • RP

  • Graves disease • Pain


Review of systems

Review of Systems


A case of cauliflower ears

  • 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 systems1

Review of Systems


Review of systems2

Review of Systems


Review of systems3

Review of Systems


Review of systems4

Review of Systems


Review of systems5

Review of Systems


Pain history

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 history1

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


A case of cauliflower ears

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


A case of cauliflower ears

DRPs

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


Question

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

Therapeutic Options

  • No change in therapy

  • Infliximab

  • Rituximab

  • Azathioprine

  • Cyclophosphamide


Clinical question

Clinical Question


Search strategy

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 20091

Leroux et al. Arthritis & Rheumatism 2009


Leroux et al arthritis rheumatism 20092

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 20093

Leroux et al. Arthritis & Rheumatism 2009


Marie et al rheumatology 2009

Marie et al. Rheumatology 2009


Buonuomo et al rheumatol int 2009

Buonuomo et al. Rheumatol Int 2009


Richez et al rheumatol int 2009

Richez et al. Rheumatol Int 2009


Goals of therapy

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

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


Recommendation1

Recommendation

  • Improve pain control

    • Discontinue Codeine Contin

    • Start Morphine 30mg long acting q 12h

    • Start Morphine IR 5mg prn for breakthrough pain


Recommendation2

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


Monitoring1

Monitoring


Follow up feb 2010

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

Questions?


References

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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