Sydney Broome Fremantle Analgesics for musculoskeletal pain PowerPoint Presentation

Sydney Broome Fremantle Analgesics for musculoskeletal pain PowerPoint Presentation

2018-12-08 5K 5 0 0

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1. Nociceptive pain . Neuropathic pain. Due to a lesion or disease of the somatosensory nervous system. Nociplastic. pain. Sensitization (amplification). Modulation. Allodynia. EJ Visser Churack Chair UNDA 2018 copyright. ID: 738301

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Presentations text content in Sydney Broome Fremantle Analgesics for musculoskeletal pain

Slide1

Sydney

Broome

Fremantle

Analgesics for musculoskeletal pain

1

Slide2

Nociceptive pain

Neuropathic pain

Due to a lesion or disease of the somatosensory nervous system

Nociplastic

pain

Sensitization (amplification)Modulation

Allodynia

EJ Visser Churack Chair UNDA 2018 copyright

2

Pain

Slide3

Pharmacotherapy: part of a multimodal pain

Mx

approach

Acute

pain reliefacute

to chronic pain transitionfunctional rehabilitation (physiotherapy)

risk of adverse effects

chemical coping, addiction

Mx

chronic pain

EJ Visser Churack Chair UNDA 2018 copyright

3

Aims of analgesia

Slide4

Lets review the drug cupboard

Slide5

Paracetamol

Not sure

how

paracetamol works?

COX-2, ‘cannabinoid’, serotonin?

Maximum 8 per day Mainstay analgesic in most pain protocols

No

good for acute or chronic pain (Cochrane)

individual responders

older patients

Combination paracetamol analgesics are more effective

Slide6

Analgesia league table

NNT

Celecoxib

400 2

Ibuprofen 400 2.5Paracetamol 500 + ibuprofen 200 1.8

Paracetamol 650 + tramadol 75 2.6

Panadeine forte 60/1000 3

Paracetamol 1000 4

Oxycodone 5 mg 4

Tramadol 100mg

5

Codeine

60mg 17

Slide7

NSAIDs &

coxibs

NSAIDS: ibuprofen, aspirin

COXIBS: celecoxib (COX-2 selective)

Anti-inflammatories

Prostaglandin synthesis (COX)

Good prostaglandins (housekeeping)

Renal & gastric risk

Cardiovascular risk

Bleeding risk

Vessels Platelets

Gut

Kidney

Bone healing

Airway

Tissue healing

Slide8

NSAIDs &

coxibs

Celecoxib

Ibuprofen, naproxen, diclofenac

Effective for acute pain (NNT <3)

≤7 days

Not for chronic

pain Rapid-acting formulations ARE better

Side effects (belly, bladder, bleeding)

Slide9

Analgesia league table

NNT

Celecoxib

400 2Ibuprofen 400 2.5

Paracetamol 500 + ibuprofen 200 1.8

Paracetamol 650 + tramadol 75 2.6

Panadeine forte 60/1000 3

Paracetamol 1000 4

Oxycodone 5 mg 4

Tramadol 100mg

5

Codeine

60mg 17

Slide10

Tramadol

Opioid, noradrenaline, serotonin

Acute pain

Neuropathic pain (NNT 4)

Respiratory depression & constipation

Addiction (S4)

Ineffective in

10

% (prodrug, 2D6 enzyme)

Renal accumulation, seizures, interactions, serotonin

 

Opioids

Noradrenaline

S

erotonin

Slide11

Analgesia league table

NNT

Celecoxib 400 2

Ibuprofen 400 2.5

Paracetamol 500 + ibuprofen 200 1.8

Paracetamol 650 + tramadol 75 2.6

Panadeine forte 60/1000

3

Paracetamol 1000 4

Oxycodone 5 4

Tramadol 100 4

Codeine

60 15

Slide12

Tapentadol

(Palexia

)

‘Weak’ opioid (S8) & noradrenaline analgesic

Similar to tramadol without serotonin

Side effects

Acute pain

Neuropathic pain

Chronic pain

 

Slide13

O

pioids for chronic pain

Poor risk

vs

benefit

Don’t work well (NNT = 8, NNH

= 4) (Level I

)Risk of adverse effects

classical side effects, tolerance, hyperalgesia, overuse, addiction

Contraindicated in non specific spinal pain, fibromyalgia

OK to

trial

in >60s with spondylosis or OA joint pain

3Ts:

tramadol SR,

tapentadol

SR,

transdermal

buprenorphine

Ceiling

dose

is

60

mg oral morphine

equivalents/day

13

Slide14

Combination analgesics

For acute pain only

Paracetamol 500 mg/ ibuprofen 200 mg (OTC)

Paracetamol 325 mg/ tramadol 37.5 mg (

Zaldiar

) (script)

Paracetamol 500 mg/ codeine 30 mg (script)

Ibuprofen 200 mg/ codeine 12 mg (Nurofen plus) (script)

Slide15

Analgesia league table

NNT

Celecoxib 400 2

Ibuprofen 400 2.5

Paracetamol 500 + ibuprofen 200 1.8Paracetamol 650 + tramadol 75 2.6

Panadeine

forte 60/1000 3

Paracetamol 1000 4

Oxycodone 5 4

Tramadol 100

5

Codeine

60 17

Slide16

Antidepressants & anticonvulsants

NOT

effective for

nociceptive pain

Duloxetine (SNRI) is moderately effective (noradrenaline effect)

Chronic LBP & knee pain

Neuropathic pain (NNT

4)

Pregabalin

,

gabapentin

Not

effective for

LBP

Radicular

leg

pain?

Slide17

Other analgesics

Topical NSAIDs

OA knee, hands,

enthesopathy

, tendonopathy

Topical capsaicin cream

OA knee, hands

Menthol 4% gel

17

Slide18

EJ Visser Churack Chair UNDA 2017 copyright

18

Oral (prednisolone)

Acute inflammatory arthritis, tendonitis, enthesitis, myositis

Early CRPS?

Acute radiculopathy?

Injection

Radicular leg pain (transforaminal

epidural)

Knee, hip, shoulder, facet, SIJ, soft tissues

Steroids

Slide19

Vitamin C 1000 mg/d for

4 weeks

CRPSO

2 free radical scavenger

neurogenic inflammationEJ Visser Churack Chair UNDA 2017 copyright

19

Distal limb injuries

Slide20

EJ Visser Churack Chair UNDA 2017 copyright

20

Sleep

Melatonin, valerian, lavender

Amitriptyline, pregabalin

Anti-inflammatories

Curcumin

PEA (lecithin nutraceutical)

Chondroitin & glucosamine

Sleep & supplements

Slide21

EJ Visser Churack Chair UNDA 2017 copyright

21

Neuroimmune & glial modulators

Fibromyalgia, CFS, CRPS

Melatonin

Minocycline (antibiotic)Metformin (diabetes)

Naltrexone

Cutting edge?

Slide22

EJ Visser Churack Chair UNDA 2017 copyright

22

Codeine

Cannabinoids Benefits < risks

NNT 15 for both Individual responders?

Muscle spasms

Orphenadrine or baclofen

(

diazepam*)

for muscle spasms

Controversies

Slide23

Acute musculoskeletal pain

Comfort measures (heat)

Combination

paracetamol/ibuprofen

prn (≤ 4 days)

Severe…Celecoxib 100-200 mg

bd (≤ 7 days)

Combination paracetamol/tramadol or codeine prn

OR…

IR

tapentadol

or oxycodone

prn

≤ 4/24

prn, ≤ 4 x daily, ≤ 4 days

Slide24

Acute

severe

radicular pain

Neuropathic pain (nociceptive, muscle spasms)

Analgesics are poorly effective (level

I)Tramadol,

tapentadol or oxycodone

Pregabalin

Steroids (

transforaminal

injection or oral)

Natural history; improvement in 3-6 months

Slide25

Thank you


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