Inhaled isopropyl alcohol for nausea

An elderly male presents to the emergency department with complaints of nausea, vomiting, and diarrhea starting a day and a half ago.  The diarrhea started abruptly, has occurred almost 10 times, and is non-bloody.  His abdomen is soft but has mild diffuse tenderness.  Vital signs and basic laboratory results are normal except for a potassium of 2.9 mEq/L and an EKG with a QTc interval of 490 msec. 

Prevention of postherpetic neuralgia

An elderly patient is admitted to the internal medicine service with a diagnosis of herpes zoster infection in the typical dermatomal distribution.  The patient’s rash is currently not very painful (2/10) but she is concerned about long-lasting pain as her friend had pain from zoster that lasted for months.  What can we use to prevent the development of postherpetic neuralgia?

Postherpetic neuralgia is a common complication of herpes zoster infection and can be challenging to treat.  Drugs approved by the FDA to treat postherpetic neuralgia include pregabalin (Lyrica), gabapentin (Neurontin), and capsaicin patch (high-concentration patch - Qutenza).  Other medications that have been shown in randomized controlled trials to also reduce pain from postherpetic neuralgia include topical lidocaine, tricyclic antidepressants (eg. nortriptyline), opioids, and tramadol¹. 

No medication has been approved for the prevention of postherpetic neuralgia but here is the data on several agents that have been studied:

Capsaicin for osteoarthritis

Let’s begin with a patient case.  An elderly patient is being treated with acetaminophen 650 mg po q6hr prn osteoarthritis pain of the hands.  She takes all four doses on most days and does not feel this relieves her symptoms adequately.  She has multiple comorbidities and is looking for some therapy with improved efficacy.  She wants to know if Capzasin® over-the-counter would be a good choice.

Dosing colchicine in acute gouty arthritis

Let’s start with a patient case.  An elderly patient with multiple comorbidities is being treated in the hospital for heart failure when he develops an acute gouty attack.  His past medical history, among other things, includes CKD (Stage 4).  Should colchicine be used in this patient and if so, what dose would be indicated?

The American College of Rheumatology guidelines for the treatment of acute gout consider colchicine, NSAIDs, and corticosteroids all first line monotherapy (Evidence A) for moderate severity pain in 1-2 joints.  A combination of these is appropriate to consider in severe pain (Evidence C).  Since all have the same grade evidence for first line therapy, agent selection should be based on prior response, comorbidities, and patient preference while also considering each agent’s drug interactions.