# A 60-year-old woman with fibromyalgia and major depression has been taking duloxetine 60 mg PO daily for 1 year. She reports she drinks 2-3 glasses of wine every evening and the urgent care clinic just prescribed tramadol 50 mg every 6 hours as needed for a back strain. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375258&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 60-year-old woman with fibromyalgia and major depression has been taking duloxetine 60 mg PO daily for 1 year. She reports she drinks 2-3 glasses of wine every evening and the urgent care clinic just prescribed tramadol 50 mg every 6 hours as needed for a back strain. Which action should the nurse take?

## Option

1. Reassure the patient that taking tramadol 50 mg every 6 hours as needed with duloxetine is safe if she reduces alcohol to one drink per evening and monitors for drowsiness.
2. Notify the prescriber about the daily alcohol use and the new tramadol order, request liver function tests and a serotonin syndrome safety review, and discuss alternative analgesics. **✔ Correct answer**
3. Instruct the patient to discontinue duloxetine on her own while taking tramadol, because the combination can cause excessive sedation, and resume it when the back pain resolves.
4. Recommend that the patient reduce her alcohol intake to one glass of wine daily, and then start the tramadol as prescribed without requesting liver function tests or a medication review.

**Correct answer: 2**

## Explanation

This patient has TWO converging risks. (1) Hepatotoxicity: duloxetine is contraindicated with substantial alcohol use (≥3 drinks/day or chronic) and any pre-existing liver disease — combined exposure raises ALT/AST and the rare risk of liver failure. (2) Serotonin syndrome: duloxetine + tramadol stacks two serotonergic agents, and tramadol also lowers seizure threshold. The nurse must escalate to the prescriber: alcohol/SUD assessment, LFTs, switch to a non-serotonergic analgesic (acetaminophen with caution given liver, lidocaine patch, NSAID with GI risk balance), and education on serotonin syndrome warning signs (clonus, hyperreflexia, agitation, fever). Reassurance, self-stopping the SNRI, or only telling her to drink less all miss the actual safety problem.

## In-depth explanation

Two-hit problem: alcohol + duloxetine = liver, duloxetine + tramadol = serotonin. Both must be addressed at once, not separately.

## Clinical scenario

Scenario 60-year-old woman, MDD + fibromyalgia, on duloxetine 60 mg PO daily for 1 year. She drinks 2-3 glasses of wine nightly. Urgent care clinic ordered tramadol 50 mg PO q6h PRN for an acute lumbar strain. No prior LFTs available in chart; no signs of overt liver disease today, no jaundice, no asterixis, AOx3, vital signs stable. No SSRI/MAOI/triptan/St. John wort on the medication list.

## Key concepts

- **Duloxetine hepatotoxicity** — Boxed and labeled warning: avoid duloxetine in patients with substantial alcohol use or chronic liver disease. Hepatic injury usually occurs within 2 months but can be delayed; monitor LFTs if risk factors present and stop the drug for ALT >3x ULN.
- **Serotonin syndrome** — Triad of mental status change, autonomic instability, and neuromuscular hyperactivity (clonus, hyperreflexia). Caused by stacking serotonergic drugs (SSRI/SNRI + tramadol/triptans/MAOI/St. John wort/linezolid). Treatment: stop offending drugs, supportive care, cyproheptadine in severe cases.
- **Tramadol cautions** — Schedule IV opioid that is also an SNRI; lowers seizure threshold and contributes to serotonin syndrome with other serotonergic drugs. Avoid in seizure disorders, in children under 12, in post-tonsillectomy children, and in patients on high-risk co-medications without review.

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