Factors known to elevate the risk of developing a GI ulcer include: a. Being older than age 65. b. History of GI ulcer. c. High doses of aspirin and/or other NSAIDs. d. Taking multiple aspirins and/or other NSAIDs (dual or duplicative therapy). e. Use of drugs associated with damage to the GI tract (corticosteroids, anticoagulants). f. Use of tobacco and/or alcohol. g. Obesity. h. Some chronic illnesses. (Christensen et al., 2007; Garrow & Delegge, 2010; Goodman et al., 2018; Rahme, Bardou, et al., 2007; Rahme, Barkun, et al., 2007) A history of chronic obstructive pulmonary disease, renal insufficiency, and heart disease is associated with an increased risk of developing a GI ulcer, but diabetes is not associated with an increased risk of developing a GI ulcer (Garrow & Delegge, 2010). Boissonnault and Meek (2002) reported in a study of 2,311 outpatients seeking physical therapy services that 79% of the patients were taking aspirin and/or another NSAID. Although 42% of those patients reported taking only a single aspirin or other NSAID, 37% reported combined anti-inflammatory therapies (i.e., they were taking more than one form of aspirin and/or other type of NSAID). About 18% of the subjects reported taking an aspirin and another NSAID (dual therapy), Specific adverse reactions In screening for an adverse drug reaction, the therapist is encouraged to consider the common side effects noted for the top 20 prescription drugs and common OTC analgesics described above and in Table 18. Although there are many reported side effects for each of these medications, the therapist should recognize that an adverse drug reaction should result in the patient providing an affirmative answer to one or more general health questions (i.e., the patient has a change in constitutional symptoms) and some of the screening questions for specific physiological systems. The likelihood of an adverse drug reaction is increased if the onset of symptoms, or a change in symptoms, coincides with starting a new medication or a change in the dose of a medication, since many side effects are dose related. In addition, one of the most common adverse reactions of all medications is amplification of the intended pharmacological response. The term amplification is used to describe an exaggeration of the intended therapeutic response to the drug. For example, a person taking a medication to lower his or her blood pressure may experience symptoms of hypotension if the medication lowers the blood pressure more than intended. The list of side effects for many medications is long. One option is for the therapist to screen appropriately for these side effects is to use the general health questions to screen for the presence Subjective examination Ken is a 53-year-old male with a history of low back pain (LBP) for 3 months who was referred by his family physician to physical therapy. The patient reported that the physician did not conduct a physical exam specific to the back nor order any imaging. The patient reported that the physician simply told him to “take it easy” and referred him to physical therapy. Ken was told to come back if his LBP did not improve within 1 month. No prescriptions were offered at that time.
while approximately 19% reported taking two or more medications from the same class (duplicative therapy). For example, a patient taking OTC ibuprofen (Motrin, Advil) is given a prescription for Motrin and takes both (duplicative therapy), or a patient taking OTC aspirin is given a prescription for Motrin and takes both (dual therapy). Boissonnault and Meek (2002) noted that 4% of the subjects in the study reported taking a prescription medication to treat an ulcer and 21% reported taking an antacid for relief of gastric distress. The introduction of NSAIDs with selective COX-2 inhibition in Denmark in 1999 resulted in a 44% increase in the total number of prescriptions written annually for NSAIDs by 2004. In fact, the increased use of NSAIDs was due primarily to the introduction of COX-2 inhibitors (Christensen et al., 2007). During this same time period, the hospitalization rate for bleeding ulcers remained stable, while the hospitalization rate for perforating ulcers decreased significantly (Christensen et al., 2007). Thus, the introduction of COX-2 inhibitors coincided with a stable hospitalization rate for bleeding ulcers, while the hospitalization rate for perforating ulcers decreased, supporting the hypothesis that COX-2 inhibitors have lower GI toxicity compared to nonselective NSAIDs. However, COX-2 inhibitors are associated with some serious side effects, including a 2.5-fold increase in the risk of a major fatal or nonfatal cardiovascular event (Rahme, Bardou, et al., 2007) and therefore these medications are not recommended nor prescribed any longer unless the client has an elevated risk of ulcers and requires NSAID. of a potential adverse drug reaction. When information from the general health questions is combined with the medication history and an awareness of the physiological system or systems most frequently affected by an adverse drug reaction, the therapist can better focus and direct their questions. Although any physiological system could be affected by an adverse drug reaction, five physiological systems are frequently associated with an adverse drug reaction – the GI system, pulmonary system, CNS, integumentary system, and musculoskeletal system (Adams & Holland, 2011). Table 18 lists the commonly reported symptoms associated with an adverse drug reaction for each of the five systems as well as the types of medication most frequently associated with those adverse reactions. In addition, the therapist should remember which medications produce the largest number of adverse reactions and the physiological systems most commonly affected. Aspirin, the other NSAIDs, and opioids are used frequently to treat the pain and inflammation found in many outpatients with musculoskeletal disorders. These medications are frequently known to produce adverse drug reactions in the GI system, and as a result, any patient reporting their use should be screened for the presence of GI distress. Medical and personal history The patient reported that his medical history was absent of any medical conditions or co-morbidities. He denied being treated for any medical conditions currently other than the current episode of LBP. He denied taking any prescription medications currently beyond his use of ibuprofen for his LBP. The patient lived independently in a two-story home. He reported difficulty with the stairs so he had confined himself to the first floor for the last month. The patient previously enjoyed hiking and riding motorcycles with his friends but has been unable to do so for the last 3 months. He hoped to return to those activities with his friends soon. These activities were currently limited by his
CASE STUDY 1: UNDIAGNOSED LOW BACK PAIN
Page 99
Book Code: PTOH1324
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