1. Case Study A) 81 y old male in LTCF with primary learning disability and cervico-dorso-lombarthrosis treated by WHO level 1 painkiller B) During the absence of the GP, the patient was addressed to a rheumatologist for his known pain: after 3 consultations with blood tests and Rx (all negative!!), an hypothetical diagnosis of rheumatoid disease was evocated…. (Eular test: 2 pts!!) C) Over 6 months the medications were increased: corticoids(prednisone); ledertrexate: with no better results (VAS 3-4/10 max!), mainly because the patient was focused on painkiller even when he had difficulties to express the symptoms and was still rather autonomous D) A last step of therapeutic escalation was the introduction (due to? poor communication of the patient and language barrier between both!) of an TNFalpha inhibitor (Enbrel 50 mg 1/week SC) E) After 6 months, with regular blood testing, an urgent call for visiting the patient indicated: fever, numerous buccal aphthous lesions and bronchopneumonia associated to diarrhea. Labor results: pancytopenia with leukopenia 1.3 giga/l; neutrophils at 0.38 giga/l; Hb at 9.8 g/dl and thrombopenia at 39 giga/l F) Urgent treatment plan: isolation of the patient immediate stop of Enbrel double antibiotic treatment every 2d day: blood test Patient recovered status quo ante in 1 month!!
2. Conclusions and lessons learned: Patient’s symptoms have been correlated to complementary investigations Patients with LD should be accompanied Medical escalation has to be questioned, but the most important: Less is More in Geriatrics
Mónica Calle García. From Simple Painkiller to an TNF-Alpha Inhibitor and Back Again or Doing Less is Always More in Geriatrics. Annals of Clinical and Medical Case Reports 2021