Question
A 47-year-old man comes to the physician because of intermittent lower back pain for 1 week. His symptoms began shortly after lifting heavy boxes at work. He has not had any fever, chills, or weight loss. He has a history of peptic ulcer disease. He does not smoke or drink alcohol. His vital signs are within normal limits. Examination shows mild paraspinal lumbar tenderness. Neurologic examination shows no focal findings. An x-ray of the spine shows no abnormalities. Which of the following is the most appropriate initial pharmacotherapy?
| A. |
Aspirin
|
| B. |
Acetaminophen
|
| C. |
Oxycodone
|
| D. |
Naproxen
|
Show Answer
|
Correct Answer � B
Explanation
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|
Ans-B-Acetaminophen
Aspirin
Aspirin is an agent in the NSAID class. NSAIDs would be contraindicated in this patient with a history of PUD as they reduce production of protective mucosal prostaglandins. Use of NSAIDs in patients with PUD can increase the risk of complications including gastrointestinal bleeding and perforation.
Acetaminophen
NSAIDs (e.g., ibuprofen, naproxen, aspirin), which inhibit both COX-1 and COX-2 peripherally, are contraindicated in this patient with PUD because they reduce synthesis of gastroprotective prostaglandins. Acetaminophen, which is not an NSAID, has analgesic effects because it inhibits COX in the CNS but it is inactivated peripherally and therefore does not cause gastric side effects. Another treatment option for this patient would be selective COX-2 inhibitors (e.g., celecoxib), which spare COX-1 in the gastric mucosa and, hence, spare mucosal prostaglandins.
Oxycodone
Oxycodone as well as other opioids would not be indicated as a first-line therapy for a patient with only mild musculoskeletal back pain. Opioids are reserved for treatment of severe or refractory back pain (e.g., tumor pain).
Naproxen
Naproxen is an agent in the NSAID class. NSAIDs would be contraindicated in this patient with a history of PUD as they reduce production of the protective mucosal prostaglandins. Use of NSAIDs in patients with PUD can increase the risk of complications including gastrointestinal bleeding and perforation.
