背景:唑来膦酸盐,双膦酸盐,是骨质疏松症的有效一线治疗方法。它也是高钙血症的优选治疗,特别是当对静脉内流体无反应时。双膦酸盐可引起类似阿片类药物戒断症状的急性期反应,这可能会混淆提供者的决策。我们的病例突出了涉及阿片类药物使用障碍患者的认知偏见,该患者接受唑来膦酸钠治疗继发于固定和严重骨感染的高钙血症。
方法:一名41岁男性入院,既往有积极静脉阿片类药物使用史,并发A组链球菌菌血症伴L5-S1椎间盘炎和骨髓炎,L2-L3骨髓炎,左踝关节冲洗后左踝关节脓肿/化脓性关节炎状态。通过输注氯胺酮的急性疼痛服务(较早停止),他的疼痛得到了很好的控制,阿片类药物,对乙酰氨基酚,丁丙诺啡-纳洛酮,环苯扎林,加巴喷丁,还有萘普生.停用静脉阿片类药物,轻微减少阿片类药物方案。一天后,病人报告了心动过速,排汗,肌痛,和寒冷,主要团队重新咨询了急性疼痛服务以戒断阿片类药物。然而,患者因高钙血症接受了唑来膦酸盐输注,在同一天停用静脉注射阿片类药物.根据图表审查,他没有其他已知会引起戒断样症状的药物。因此,怀疑发生了急性期反应,通常在使用双膦酸盐的几天内出现。
结论:唑来膦酸盐,以引起急性期反应而闻名,可能是戒断样症状的原因。双磷酸盐的急性期反应主要发生在第一次输注时,发病率随着随后的输注而降低。症状通常发生在输注后24-72小时,最多持续72小时。认知偏见导致主要团队关注阿片类药物戒断,而不是调查患者表现的其他原因。因此,提供者应彻底调查潜在的病因,并相应地排除它们,以提供最佳的治疗。医疗保健提供者还应意识到潜在影响他们为患者提供的护理质量的隐含偏见。
Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our
case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection.
A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use.
Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient\'s presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients.