PAIN MANAGEMENT MERCHÁN CUENDA, MERCEDES MILÁN RODRIGUEZ, MARÍA MILAGROS MORENO MARÍN, EDUARDO NEVADO VILLAFRUELA, MARINA MUÑOZ GARRIDO, JESÚS ÁNGEL
PAIN MANAGEMENT
MERCHÁN CUENDA, MERCEDESMILÁN RODRIGUEZ, MARÍA MILAGROS
MORENO MARÍN, EDUARDONEVADO VILLAFRUELA, MARINAMUÑOZ GARRIDO, JESÚS ÁNGEL
Acute Pain Management
Acute GastritisPain treatment Analgesics
Etiological treatment
No specific therapy exists for acute gastritis, except for cases caused by H pylori.
- Omeprazole.- Clarithromycin:
500 mg PO bid/tid.- Amoxicillin: 500
mg PO qid.
Drug Dose Side effects
Antacids Magnesium/
aluminum
650 mg to 1.3 g tab PO
qid.
Rarely
H2 Blockers Cimetidine 50 mg PO
qid; not to exceed 600
mg/d.
Rarely: aplastic anaemia
Proton pump
inhibitors
Omeprazole 20 mg PO bid.
Low GI
Acute otitis media pain
3 drops of topical 2% lidocaine drops or benzocaine
Rapid pain relief
Antibiotics will not provide immediate pain relief and oral analgesics will take a while to help.
Acute renal colic pain First-line therapy Metamizol Second-line therapy Pethidine
Drug Dose Side effects
Precautions
Metamizol 1 vial (2g) IV q8h; not to
exceed 3vials/d.
Agranulocytosis (rare)
Very slow administratio
n (3-5min)
Pethidine 50-100 mg IV. - Drowsiness- Respiratory
depression- Constipation
Very slow administratio
n
Back pain First-line therapy NSAIDs Ibuprofen: 600-2400 PO mg/d q6-8h(600mg/6h).
Naproxen: 550-1100 PO mg/d. Initial dose: 550mg, followed 275mg q6-8h.
Second-line therapy
Opioids
Dysmenorrhea First-line therapy
NSAIDs Ibuprofen: 400 mg PO q4-6h; not to exceed 3.2 g/d.
Naproxen: 550-1100 PO mg/d. Initial dose: 550mg, followed 275mg q6-8h.
Prophylaxis
Oral Contraceptives Pill
Tension headacheDrug Dose Side effects Precautions
Metamizol1 vial (2g) IV
or IM q8h; not to exceed 3vials/d.
Agranulocytosis (rare)
Very slow administration
(3-5min)
Diazepam2-10 mg IM,
repeat at 3-4 h if is need it
- Drowsiness-Cardiorespirato
ry failure (IV) Alcohol
Metoclopra-mide
15 to 40-60 mg/d PO
divided in 2-4 times. Max dose: 0.5 mg/kg/d.
Extrapyramidal effects
Chronic Pain
NEUROPATHIC PAIN
Pain caused by lesion or dysfunction of the somatosensory system
NON-CANCER PAIN
CANCER PAIN
The most common causes are:
Diabetes mellitusPost-herpetic neuralgiaTrigeminal neuralgiaCancer
1. FIRST-LINE TREATMENT:Tricyclic antidepressants:
AMITRIPTYLINE, IMIPRAMINE, NORTRIPTYLINE
2. SECOND-LINE: Anticonvulsivants:
PREGABALIN, GABAPENTIN
3. THIRD-LINE TREATMEN:-TRAMADOL-OPIOIDS: OXYCODONE, METHADONE, MORPHINE-SNRIs: VENLAFAXINET
Effective doses 10 -100 mg
2 weeks at least to get efficacy
Start at low dose and increase it.
Adverse effects: dry mouth,constipation, sweating, dizziness, sedation, drowsiness, palpitation, orthostatic dysregulation and urinary retention.
Caution!!!! in elderly patients and with cardiovascular risk factors.
if TCAs are contraindicated, not tolerated, ineffective or if a rapid onset of effect is needed in acute neuropathic pain states.
PREGABALIN: 75 mg bd, maximum dose 300 mg bd.
Post-herpetic neuralgia
TOPIC LIDOCAINE 5% patch 24 h.
PREGABALINE•Start with 150 mg/daily in 2-3 times.•Later 3-7 days, if it is neccesary increase doses until 300 mg/daily in 2-3 times.•Later 7 days if is necessary increase doses until to maximun to 600 mg/ daily in 2-3 times.
Capsaicin cream
Topical Nonsteroidal Anti-inflammatory Drugs
Amitriptilin
Trigeminal neuralgiaIs an uncommon disorder characterized by recurrent attacks of
lancinating pain in the trigeminal nerve distribution.
CARBAMAZEPINEHas several adverse effects, but is highly efficacy: signs of blood, hepatic or skin disorders – seek medical advice if fever, sore throat, rash or mouth ulcers, bruising/bleeding develop. In adition: sickness, nausea & vomiting, visual disturbances.
Interaction: oral anticoagulants, oral contraceptives,MOAIs, anticonvulsivants.
Dose: 100- 16oo mg ODstarting at 100mg bid Habitual doses: 200 mg/day tidIt can increase in 100-2oo mg in two weeks.
First-line agents:Duloxetine (SNRIs)PregabalinTCAs: amitriptylin
Second-line agents:Gabapentin : 900-3000 mg/d
Lamotrigine: 400 mg/d
Venlafaxine: 150 to 225 mg
Tramadol: 50-400 mg/d
Pain in Diabetic neurophaty
60 mg Less side effects than TCAs and more tolerable:asthenia, constipation, dizziness, dry mouth, hyperhidrosis, nausea, and somnolence.
PRECAUTION!!: High blood pressure and heart disease!!No association: TAC, SSRI, MAOI!!
CHRONIC NOCICEPTIVE PAINNociceptive pain refers to the discomfort that results when a stimulus causes tissue damage to the muscles, bones, skin or internal organs.
Fibromyalgia: therapeutic agents
SNRIs:
DULOXETINE 30-60 mg bid
TACs: AMITRIPTYLIN in low doses (10–25 mg)
Analgesic: NSAIDs, TRAMADOL +/- acetaminophen, opiods
PREGABALIN
Relieve depression and pain but not insomnia ,
High blood pressure and heart disease!!No association: TAC, SSRI, MAOI!!
Relieve insomnia and pain but not depression
Improve relieve and pain but not insomnia
Fibromyalgia management
PAIN
DEPRESSION
INSOMNIA
TRAMADOL, NSAIDs
DULOXETIN
PREGABALIN
The main treatment goals with rheumatoid arthritis are to control inflammation and slow or stop progression of RA.
Treatment is a multifaceted program:
Medications + physical therapy + regular exercise.
1.Nonsteroidal anti-inflammatory drug (NSAID):
Ibuprofen (Advil ® or Motrin ®)
2.Steroids: For severe RA, used temporarily . Given as injections directly into an inflamed joint or taken as a pill.
Potential side effects of long-term steroid use include high blood pressure, osteoporosis, and diabetes.
Arthritis
Medication is the most popular way to manage osteoporosis pain.
1.Pain medications: Ibuprofen (NSAIDS)
2.Heat and ice:
Warm showers or hot packs
Osteoporosis
3.Calcitoninis
Miacalcin® :For pain in bone fractures.
Calcitonin can be taken in a nasal spray, as a shot into the muscle (intramuscular, or IM), or as a shot into the fat tissue (subcutaneous).
Side effects of the nasal spray :
Runny nose or nasal discomfort.
Side effects of the shot :
Nausea, vomiting or diarrhea.
■Nonsteroidal anti-inflammatory drugs (NSAIDs).
Ibuprofen (Advil ® ) for mild migraines. Excedrin Migraine® (Acetaminophen +aspirin+ caffeine) for moderate migraines
■Triptans.
Medications like Sumatriptan ( Imitrex ® ).
For severe migraine attacks.
Relieve the pain, nausea and sensitivity to light and sound.
Side effects of triptans : nausea, dizziness and muscle weakness.They aren't recommended for people at risk for strokes and heart attacks
Migraine
MetamizolNot use it
IbuprofenNot use it
NaproxenNot use it
MetroclopramideContraindication in lactation
DiazepamNot use it
Oral contraceptives pillsNot use it
OmeprazolThere is not evidence of fetal risk
ParacetamolThere is not evidence of fetal risk
Pregnancy and Lactation
Carefull evaluation of conditions as imperative to pain management
Assessment of effectiveness and ADR
Physiological alteration in body composition and renal and hepatic funtion
Distribuition and elimination of medications and metabolites
alter
Again and chronic conditions
Limitation in responses to stress in the elderlyand management of pain
contribuyed to
Non-medical treatments● May be effective in managing pain● Should be considered for older patiens
Old people
Risks Reye SindromMetabolic acidosis (<1 year old)
Acetylsalicylic acidNot use it
Childrens
35-year-old man come to urgency with acute renal colic pain. What would you do? First-line therapy Metamizol Second-line therapy Pethidine
What treatment would you prescribe for a severe migrain?
A)NSAIDS
B)TRIPTANS
26-year-old woman with moderate acute pain during menstruation. ¿What is the first-line therapy?
NSAIDs Ibuprofen or Naproxen
What drug do you prescribe to treat a trigeminal neuralgia?
Should you have any precaution whit this?
CARBAMAZEPINE
WEBSITEShttp://www.ncbi.nlm.nih.gov/pubmed/http://content.nejm.org/http://www.thelancet.com/http://www.agemed.es/http://www.vademecum.es/http://www.who.int/http://www.diabetes.org/www.mayoclinic.com
References:Engeler DS et al. The ideal analgesic treatment for acute
renal colic--theory and practice. 2008;42(2):137-42.
Prasad S et al. Use anesthetic drops to relieve acute otitis media pain. 2008 Jan;93(1):40-4.
St. Onge et al. Pain Associated with Diabetic Peripheral Neuropathy. A Review of Available Treatments. 2008 Mar;33(3):166-76. 2008 March.
Tomasz Podolecki et al. Fibromyalgia: pathogenetic, diagnostic and therapeutic concerns. 2009 Mar;119(3):157-61.