Disclosures: Kyla Kosidowski: No financial relationships or conflicts of interest

Case Diagnosis: This is an occurrence of complex regional pain syndrome following ORIF of right tibial pilon fracture in patient with CYP2D6 deficiency.

Case Description or Program Description: A 26-year-old male with CYP2D6 deficiency presented to the ED with fever and worsening right leg pain two days after ORIF of right tibial pilon fracture. The patient was found to have RLE compartment syndrome and underwent fasciotomy, three I&D’s, and wound closure over the week. The patient was prescribed morphine ER 15mg Q8H, oxycodone 15mg Q4H, and gabapentin 300mg TID upon discharge. He was referred by orthopedics due to continued pain, after they had documented a CYP2D6 deficiency.

Setting: Rehabilitation hospital and outpatient clinic

Assessment/Results: On evaluation the patient’s opioids were discontinued, and Cymbalta, Tizanidine, Tylenol and Gabapentin were prescribed. In therapy we utilized range of motion, desensitization and manual therapies. Eight weeks later he was pain free, weight bearing as tolerated, and off all medications.

Discussion (relevance): CYP2D6 deficiency leads to poor metabolism of drugs that are substrates of the enzyme. Opioids are notable drugs that require sufficient levels of CYP2D6 to be metabolized and thus exhibit analgesic effect. This case is unique in that a CYP2D6 deficient patient’s excruciating pain from CRPS was managed without opioids and instead incorporated a comprehensive, multimodal interdisciplinary approach. This approach led to improved function and complete pain relief over an eight week period.

Conclusions: CYP2D6 deficiency is a rare condition in which individuals poorly metabolize certain drugs including opioids. For individuals with CYP2D6 deficiency, alternatives to opioid treatment are imperative for management of severe pain.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/comprehensive-multimodal-interdisciplinary-approach-to-treating-crps-in-cyp2d6-deficient-patient-without-opioids/