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Student School of Medicine University of Texas Health Science Center 7733 Louis Pasteur #402 San Antonio, Texas 78229-3472 fax 325/651-8909 heartsill{at}uthscsa.edu
Assistant Professor Department of Psychiatry University of Texas Health Science Center
Published Online, May 3, 2005. www.theannals.com, DOI 10.1345/aph.1E596
Case Report. A 56-year-old man with an anxiety disorder complicated by abuse of nicotine, alcohol, and cocaine; coronary artery disease; and peripheral vascular disease developed severe left lower leg pain. He stopped using alcohol and cocaine and cut back on his smoking, but despite these lifestyle changes, the pain progressed. At first, the patient experienced leg pain only while walking, but after stopping exercise, he then developed leg pain at rest. Doppler ultrasound studies revealed marked bilateral femoropopliteal occlusive disease, more pronounced in the left. Leg pain at rest disrupted the patient's sleep, and he became clinically depressed. He was admitted to a psychiatric inpatient service and continued on his home medications: venlafaxine 300 mg/day for depression, aspirin 325 mg/day, atenolol 50 mg/day, quetiapine 50 mg in the morning and 400 mg at night, trazodone 100 mg at night, and acetaminophen 1000 mg with hydrocodone 10 mg/day.
After a week without change in his pain or mood, the patient was started on gabapentin 600 mg 3 times a day. This was increased over one week to 1200 mg 3 times a day. At this dose, the pain was significantly reduced. The patient no longer had rest pain, was sleeping well at night, and was spontaneously ambulating and participating in physical therapy. As his pain lessened, the patient's mood improved. By the time of discharge from the hospital, he no longer had subjective evidence of chronic critical limb ischemia. Doppler ultrasound was not repeated prior to or immediately after discharge.
Discussion. Chronic pain itself may accelerate decline in chronic critical limb ischemia and can precipitate or worsen major depressive disorder.3 Major depressive disorder can cause abnormal arterial vasoconstriction and increased platelet aggregation, exacerbate ischemia, and reduce a patient's self-care.4,5 Reduced aerobic activity has a critical impact on the course of vascular disease. In our case, the symptomatic pain relief the patient obtained from a trial of gabapentin was striking and allowed a marked functional improvement.
As of April 17, 2005, gabapentin had not been reported as a treatment for rest pain in chronic limb ischemia. The safety of gabapentin alone and in combination with other agents, and the patient's marked improvement in response to gabapentin, suggest further investigation is warranted of the potential utility of gabapentin for patients with rest pain due to chronic critical limb ischemia.
References
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