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P OSTER
A BSTRACTS
ratory symptoms such as stridor and airway compromise due to RA.
The patient in this case presented with dysphagia and dysphonia
without any other respiratory symptoms. Also, this case illustrates a
unique presentation of RA in which dysphagia was not only caused
by laryngeal dysfunction but also oropharyngeal dysfunction possibly
related to striated muscle involvement, a phenomenon that has not
been very well described. Further studies are needed to investigate
pathophysiology and treatment of dysphagia and dysphonia in patients
with RA.
C26
Stuck Between a Rock and a Bare Metal Stent: Triple
Antithrombotic Therapy Resulting in a GI Bleed.
F. Longenecker, 2 B. Setters. 1 1. Family & Geriatric Medicine,
University of Louisville, Louisivlle, KY; 2. School of Medicine,
University of Louisville, Louisville, KY.
Introduction: Although the standard of care for PCI with stent
placement and DVT prophylaxis for hip arthroplasty are individually
well established, little evidence exists about what to do for patients
requiring both treatments simultaneously. In such a situation the risk
of bleeding vs. the risk of thrombosis must be used to determine the
individual patient’s treatment course.
Case Report: A 79 y/o WF was admitted with an L femoral neck
fracture after being found down for 48 hours. Preoperative clearance
determined she needed a cardiac catheterization which found a 90%
occlusion of her LAD requiring placement of a bare metal stent. She
was started on clopidogrel and aspirin therapy post stent for a minimum
of 30 days. Discussion ensued with orthopedics and cardiology
about the timing of the patient’s orthopedic procedure now that she
was on anticoagulation. Orthopedics felt that the surgery could be
safely performed on anticoagulants and performed the surgery 3 days
post-stent. She was then started on fondaparinux for DVT prophylaxis
post hip repair.
The patient was discharged to a rehabilitation center four days
post operatively with instructions to monitor for bleeding; Hemoglobin
at discharge was 10.3. Nine days later, she returned to the hospital
with dark, tarry stools worrisome for a GI bleed. Hemoglobin was 7.2
and two units of blood were transfused and pantoprazole was started.
Cardiology was consulted and it was decided the patient would remain
on aspirin but fondaparinux were discontinued to allow for an
upper endoscopic evaluation which was done the next day. She was
diagnosed with antral erosive gastritis without active bleeding. Follow
up Hemoglobin was 9.4 and without evidence of further bleeding,
clopidogrel was resumed. She remained stable and was discharged
back to her rehabilitation center with instructions for continued monitoring
and has done well.
Conclusion: Patients with indications for both DVT prophylaxis
and dual antiplatelet therapy pose a great challenge. In approaching
such cases, providers must assess each patient’s risk and benefit profile
to determine appropriate treatment and monitor for increased
risk of bleeding when combining multiple anticoagulants. Additional
recommendation for treatment and bleeding risks in patients with
bare metal stents who need DVT prophylaxis would be useful for
these cases.
C27
Gastrointestinal Bleeding as a Consequence of Bisphosphonate-
Induced Musculoskeletal Pain.
J. Seguin, 1 F. Chang, 1 K. Yeung. 2 1. School of Pharmacy, University of
Waterloo, Waterloo, ON, Canada; 2. Geriatric Medicine, North York
General Hospital, Toronto, ON, Canada.
Background:
Non-steroidal anti-inflammatory drugs (NSAIDs) are common
causes of gastrointestinal (GI) bleeds in older adults. Bisphosphonates
are first line treatment for osteoporosis, a chronic disease with
increased prevalence with aging. This case discusses how an uncommon
adverse effect associated with bisphosphonate use can be an underlying
cause to GI bleeds in older adults.
Pertinent Case History:
DA, a 79 year old community dwelling woman, was admitted
through the emergency department with acute leg and knee pain and
black stools. She was anemic with low hemoglobin (81 g/L or 8.1
g/dL), but did not require a blood transfusion. Endoscopy revealed 4
small gastric ulcers. Her pain started about 2.5 weeks prior to admission
and she was prescribed naproxen 375mg twice daily as management.
This was switched to diclofenac 75mg twice daily with rabeprazole
5 days prior to admission; however, she did not discontinue
naproxen. Upon investigation, the acute pain started with the initiation
of risedronate 35mg weekly for osteoporosis. The NSAIDs were
discontinued in hospital, and lansoprazole was initiated with acetaminophen,
as well as ferrous gluconate. She was discharged home 4
weeks later, followed by 3 months of outpatient physiotherapy.
Conclusions:
This case illustrates how missed identification of drug-related
adverse events can be harmful for the patient. Potential drug-related
causes should be investigated prior to symptomatic treatment for
pain. Practitioners should consider bisphosphonates in addition to osteoporotic
pain in their differential diagnosis for musculoskeletal
pain in the elderly. While the cause and risk factors for musculoskeletal
pain induced by bisphosphonates remain unclear, one study has
suggested that the effect may be mitigated by starting patients on
low-dose daily treatment before starting the once weekly dose. This
case also reinforces the 2009 recommendation by the American Geriatrics
Society to avoid the use of nonselective NSAIDs and COX-2
inhibitors in the elderly with persistent pain without a compelling
reason, and to exercise extreme caution if used. In addition, patient
education and reinforced understanding are pertinent to avoid therapeutic
duplications particularly with switching between agents in the
same high risk medication class.
C28
Terminal Suffering: the Complex Interplay of Pain and Delirium at
End of Life.
G. Sachdeva, 1 M. Brennan. 2 1. Internal Medicine, Baystate Medical
Center / Tufts University School of Medicine, Springfield, MA; 2.
Internal medicine/Geriatrics division, Baystate Medical Center/ Tufts
University School of Medicine, Springfield, MA.
A 70 year old man (Mr. F.) had a complex cardiopulmonary history,
anxiety, chronic pain, dysphagia, recurrent pneumonias and a
vascular dementia. Home medications included clonazepam (4 mg
over the day) a 350 mcg fentanyl patch and methadone (15 mg total
daily). He was admitted with lethargy, weakness and confusion and
proved to have a new aspiration pneumonia. His two daughters were
PAs and along with a wife and son were closely involved in decision
making. When he aspirated yet again, all agreed to strictly comfort
goals; family was deeply committed to relieving Mr. F.’s suffering. Despite
explanations that much of his restlessness and moaning was due
to a terminal delirium, the family worried he was in pain and often
declined antipsychotic doses and requested changes in the analgesic
regimen. House officers and covering hospitalists were uncomfortable
with the doses and drugs being used but certainly did not want
the patient to suffer. At times drugs (e.g. methadone) were inappropriately
discontinued but sometimes they were increased too quickly.
One day an escalation of morphine despite renal failure led to early
signs of opioid toxicity and occasional myoclonus. On another occasion,
opioids were switched because fentanyl “wasn’t working.” In
fact, the patient’s restlessness was due to urinary retention and resolved
with a catheter. With careful communication, education and
frequent reassessment, symptoms were controlled and the family
comforted. Mr. F. died calmly several days later.
AGS 2012 ANNUAL MEETING
S141