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10-minute consultation
Nick Dunn
School of Medicine, University of Southampton, Southampton SO16 5ST
A 72 year old woman on holiday in your area consults you four weeks after
starting treatment with a non-steroidal anti-inflammatory drug
(NSAID) for her painful knee. She complains of "a reaction" to the
drug. She says she has had problems with similar drugs previously,
but this drug is new and supposedly has fewer side effects. She says
she has been feeling weak and giddy and has developed a widespread
itchy skin rash. She tells you, however, that the drug was effective
as a pain reliever. You find that she also has angina and high blood
pressure.
| Reporting
adverse events in the United Kingdom
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What issues you should cover |
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History
Take a detailed history of the presenting
complaint. The exact timing of events is important, as 80% of adverse
drug reactions (usually type A
that is, pharmacologically
predictable) occur in the first month of treatment. Establish whether
she had weakness or giddiness to any extent before she began taking
the drug. Has she had or does she presently have any intercurrent
illness (for example, viral infection)? Has she any symptoms that
indicate gastrointestinal, heart, or lung disease? If the rash
started within a few days of starting the drug, and she was otherwise
well, the chance of a drug reaction is higher. Has she any history of
dyspepsia, peptic ulceration, asthma, heart failure, or renal
failure? Any of these may be exacerbated by NSAIDs and might result
in her non-specific symptoms.
Previous treatment
Has she ever had any similar rash or
gastrointestinal bleeding when she has taken any NSAID in the past?
Any such history would increase the chance of her present symptoms
being a reaction to drugs. Is she taking low dose aspirin for her
angina? This will increase the chance of gastrointestinal
bleeding.
Examination
All NSAIDs can cause gastrointestinal bleeding,
especially in elderly people. Some of these drugs are more dangerous
than others, but it is important to exclude such bleeding (palpate
the epigastrium, take pulse and blood pressure, and check for
anaemia; rectal examination for melaena may be indicated). Look for
any abnormal lung signs, as well as evidence of oedema of the ankle.
Consider renal function tests. Rash as a drug reaction can be
multifaceted and difficult to diagnose, but the commonest
manifestations are probably exanthema, urticaria, and generalised
pruritus.
| Useful reading
British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS, 2003 (No 45) Pirmohamed M, Breckenridge AM, Kitteringham NR, Park BK. Adverse drug reactions. BMJ 1998;316:1295-8 Sweetman S, ed. Martindale. The complete drug reference. 33rd ed. London: Royal Pharmaceutical Society, 2003 Dukes MNG, Aronson JK, eds. Meyler's side effects of drugs. 14th ed. Amsterdam: Elsevier, 2000 |
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What you should do |
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Footnotes |
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The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson@dphpc.ox.ac.uk)
The BMJ welcomes contributions from general practitioners to the series
This is part of a series of occasional articles on common problems in primary care
© 2003 BMJ
Publishing Group Ltd
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© 2003 BMJ Publishing Group Ltd
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