Elderly Man With Leg Pain

B.G. is an 88-year-old man currently residing in an assisted living facility (ALF). His nurse case manager (NCM) has made a referral to you for a medication review and is specifically requesting a recommendation for a pain medication to manage B.G.’s recent leg pain. The NCM reports that B.G. has been taking OTC pain medications and believes he could benefit from a prescription pain medication. B.G.’s medical history is positive for angina, heart failure, type 2 diabetes, and BPH.

B.G. is taking the following medications per a medication list supplied by his NCM: furosemide 40 mg QD; KCl 10 mEq QD; lisinopril 40 mg QD; metformin 1,000 mg BID; pioglitazone 45 mg QD; insulin glargine 10 units QHS; tamsulosin 0.4 mg QHS; and nitroglycerin 0.4 mg SL PRN.

B.G. reports worsening leg pain over the past several weeks, which has prevented him from socializing with his friends in the ALF. He reports taking OTC ibuprofen 400 mg Q4-6 hours for his leg pain. His legs are visibly swollen and edematous. B.G. confirms a 7-year history of edema due to his heart failure, but explains that the edema in his legs has become more severe over the last 2 to 3 weeks. While B.G.’s medication regimen has been fairly consistent over the last several years, his pioglitazone has been increased from 15 mg QD to 45 mg QD over the last 6 months due to a worsening of his glycemic control (A1C of 8.4% 6 months ago). Additionally, B.G. was started on insulin glargine 10 units QHS approximately 6 weeks ago.

What recommendations would you have for
B.G. and his NCM?

Joshua J. Neumiller, PharmD, CDE, CGP, FASCP
Assistant Professor
Washington State University
Spokane, Washington