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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
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
slide15
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
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
slide23
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
slide24
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
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 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
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
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
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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