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.