Medicinal

Chemistry Case 2.1 R.E. is a 48 year old chemistry professor who recently took up golf. R.E. admits to having a "Type A" personality, and he became obsessed with improving his golf swing. As a result, he now reports a great deal of pain in his left shoulder and both elbows. He has been taking Tylenol for the last four days, but does not find that the pain is very much relieved. He is now visiting his physician. Past medical history: R.E. has a history of elevated blood pressure, but it is currently well managed with medication. Over the past 10 years, R.E. has had three episodes of bleeding gastrointestinal ulcers, which R.E. has blamed on his students. These were treated with omeprazole; in every case, R.E. discontinued omeprazole use after the ulcer healed. Current medications: Propranolol, 40 mg twice daily, for hypertension Metamucil, once or twice a week, for constipation The physician calls you at the pharmacy. She wants a recommendation for treatment of this patient. You suggest: A. Switching from Tylenol to celecoxib. B. Switching from Tylenol to oxycodone. C. Switching from Tylenol to naproxen. D. Switching from Tylenol to aspirin. E. Doubling the dosage of the Tylenol. A, switching to celecoxib, is a reasonable choice. It has high COX-2 selectivity, which should minimize gastrointestinal irritation. B, switching to oxycodone, may not be such a good choice, because of the patient's tendency to constipation; this is a fairly common adverse effect of opioid analgesics. C or D, switching to naproxen or aspirin, could decrease inflammation (the Tylenol would not), so it could give more relief than the Tylenol. But there is the risk of gastrointestinal side effects, so the patient would have to be counseled about taking with food, or perhaps using omeprazole prophylactically. E, doubling the Tylenol dosage, might help with the pain, but we do not know the patient's current usage--excessive doses of Tylenol can have other adverse effects.