Decision Point OneSavella ÿ12.5 mg once daily on day 1; followed by 12.5 mg BID on day 2 and 3; ÿfollowed by 25 mg BID on days 4-7; followed by 50 mg BID thereafterRESULTS OF DECISION POINT ONEClient returns to clinic in four weeksClient comes into the office to without crutches but is limping a ÿbit. The client states that the pain is ?more manageable since I started ÿtaking that drug. I have been able to get around more on my own. The ÿpain is bad in the morning though and gets better throughout the day?. ÿOn a pain scale of 1-10; the client states that his pain is currently a ÿ4. When asked what pain level would be tolerable on a daily basis, the ÿclient states, ?I would rather have no pain but don?t think that is ÿpossible. I could live with a pain level of 3.?. When questioned ÿfurther, the PMHNP asks what makes the pain on a scale of 1-10 different ÿwhen comparing a level of 9 to his current level of 4??. The client ÿstates that since using this drug, I can get to a point on most days ÿwhere I do not need the crutches. ? The client is also asked what would ÿneed to happen to get his pain from a current level of 4 to an ÿacceptable level of 3. He states, ?If I could get to the point everyday ÿwhere I do not need the crutches for most of my day, I would be happy.?Client states that he has noticed that he frequently (over the ÿpast 2 weeks) gets bouts of sweating for no apparent reason. He also ÿstates that his sleep has ?not been so good as of lately.? He does ÿcomplain of nausea todayClient’s blood pressure and pulse are recorded as 147/92 and 110 ÿrespectively. He also admits to experiencing butterflies in his chest. ÿÿThe client denies suicidal/homicidal ideation and is still future ÿorientedDecision Point TwoContinue with current medication but lower dose to 25 mg twice a dayRESULTS OF DECISION POINT TWOClient returns to clinic in four weeksClient comes to office today with use ÿof crutches. He states that his current pain is a 7 out of 10. ?I do not ÿfeel as good as I did last month.?Client states that he is sleeping at night but woken frequently from pain down his right leg and into his footClient’s blood pressure and heart rate recorded today are 124/85 and 87 respectively. He denies any heart palpitations todayClient denies suicidal/homicidal ideation but he is discouraged about the recent slip in his pain management and looks sadDecision Point ThreeChange Savella to 25 mg orally in the MORNING and 50 mg orally at BEDTIMEGuidance to StudentThe client has a complex neuropathic ÿpain syndrome that may never respond to pain medication. Once that is ÿunderstood, the next task is to explain to the client that pain level ÿexpectations need to realistic in nature and understand that he will ÿalways have some level of pain on a daily basis. The key is to manage it ÿin a manner that allows him to continue his activities of daily living ÿwith as little discomfort as possible. Next, it is important to explain ÿthat medications are never the final answer but a part of a complex ÿregimen that includes physical therapy, possible chiropractic care, heat ÿand massage therapy, and medications. Savella is a SNRI that also ÿpossesses NMDA antagonist activity which helps in producing analgesia at ÿthe site of nerve endings. It is specifically marketed for fibromyalgia ÿand has a place in therapy for this gentleman. Tramadol is never a good ÿoption along with other opioid type analgesics. Agonists at the Mu ÿreceptors does not provide adequate pain control in these types of ÿneuropathic pain syndromes and therefore is never a good idea. It also ÿhas addictive properties which can lead to secondary drug abuse. ÿReductions in Savella can help control side effects but at a cost of ÿuncontrolled pain. It is always a good idea to start with dose ÿreductions during parts of the day that pain is most under control. The ÿaddition of Celexa with Savella needs to be done cautiously. Both ÿmedications inhibit the reuptake of serotonin and can, therefore, lead ÿto serotonin toxicity or serotonin syndrome.

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