Transcript Acute Pain Management

MERCHÁN CUENDA, MERCEDES
MILÁN RODRIGUEZ, MARÍA MILAGROS
MORENO MARÍN, EDUARDO
NEVADO VILLAFRUELA, MARINA
MUÑOZ GARRIDO, JESÚS ÁNGEL
Acute Gastritis
Pain 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
Antibiotics will not provide
immediate pain relief and oral
analgesics will take a while to
help.
3 drops of topical 2%
lidocaine
drops
or
benzocaine
Rapid pain relief
Acute renal colic pain
First-line therapy
Metamizol
Second-line therapy
Pethidine
Drug
Dose
Metamizol
1 vial (2g) IV q8h;
not to exceed
3vials/d.
Pethidine
50-100 mg IV.
Side effects
Precautions
Agranulocytosis
(rare)
Very slow
administration
(3-5min)
-Drowsiness
- Respiratory
depression
-Constipation
Very slow
administration
Back pain
First-line therapy
Ibuprofen:
600-2400 PO mg/d
q6-8h(600mg/6h).
Second-line therapy
Opioids
NSAIDs
Naproxen:
550-1100 PO mg/d. Initial
dose: 550mg, followed 275mg
q6-8h.
Dysmenorrhea
First-line therapy
NSAIDs
Ibuprofen:
Naproxen:
400 mg PO q4-6h;
not to exceed 3.2 g/d.
550-1100 PO mg/d. Initial dose:
550mg, followed 275mg q6-8h.
Prophylaxis
Oral Contraceptives Pill
Tension headache
Drug
Dose
Side effects
Precautions
Metamizol
1 vial (2g) IV or
IM q8h; not to
exceed 3vials/d.
Agranulocytosis
(rare)
Very slow
administration
(3-5min)
Diazepam
2-10 mg IM,
repeat at 3-4 h if
is need it
-Drowsiness
-Cardiorespiratory
failure (IV)
Alcohol
Metoclopramide
15 to 40-60 mg/d
PO divided in 2-4
times. Max dose:
0.5 mg/kg/d.
Extrapyramidal
effects
NEUROPATHIC PAIN
Pain caused by lesion or dysfunction of the
somatosensory system
The most common causes are:
NON-CANCER PAIN
CANCER PAIN
Diabetes mellitus
Post-herpetic neuralgia
Trigeminal neuralgia
Cancer
Effective doses 10 -100 mg
1. FIRST-LINE TREATMENT:
2 weeks at least to get efficacy
Tricyclic antidepressants:
Start at low dose and increase it.
AMITRIPTYLINE,
IMIPRAMINE,
NORTRIPTYLINE
Adverse effects: dry mouth,
constipation, sweating, dizziness, sedation,
drowsiness, palpitation, orthostatic dysregulation and
urinary retention.
Caution!!!! in elderly patients and with cardiovascular
risk factors.
2. SECOND-LINE:
Anticonvulsivants:
PREGABALIN, GABAPENTIN
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.
3. THIRD-LINE TREATMEN:
-TRAMADOL
-OPIOIDS: OXYCODONE,
METHADONE, MORPHINE
-SNRIs: VENLAFAXINET
Post-herpetic neuralgia
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.
TOPIC LIDOCAINE 5% patch 24 h.
Amitriptilin
Capsaicin cream
Topical Nonsteroidal Anti-inflammatory Drugs
Trigeminal neuralgia
Is an uncommon disorder characterized by recurrent attacks of lancinating pain
in the trigeminal nerve distribution.
CARBAMAZEPINE
Has 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 OD
starting at 100mg bid
Habitual doses: 200 mg/day tid
It can increase in 100-2oo mg in two weeks.
Pain in Diabetic neurophaty
First-line agents:
Duloxetine (SNRIs)
Pregabalin
TCAs: amitriptylin
Second-line agents:
Gabapentin : 900-3000 mg/d
Lamotrigine: 400 mg/d
Venlafaxine: 150 to 225 mg
Tramadol: 50-400 mg/d
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
PAIN
Nociceptive 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
Relieve depression and pain but
not insomnia ,
30-60 mg bid
TACs:
AMITRIPTYLIN in
low doses (10–25 mg)
Analgesic: NSAIDs,
TRAMADOL +/acetaminophen,
opiods
PREGABALIN
High blood pressure and
heart disease!!
No association: TAC, SSRI,
MAOI!!
Improve relieve and pain but
not insomnia
Relieve insomnia and pain but
not depression
Fibromyalgia management
PAIN
PREGABALIN
INSOMNIA
DULOXETIN
DEPRESSION
Arthritis
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.
Osteoporosis
Medication is the most popular way to manage osteoporosis pain.
1.Pain medications:
Ibuprofen (NSAIDS)
2.Heat and ice:
Warm showers or hot packs
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.
Migraine
■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
Pregnancy and Lactation
Metamizol
Ibuprofen
Naproxen
Metroclopramide
Diazepam
Not use it
Not use it
Not use it
Contraindication in lactation
Not use it
Oral contraceptives pills
Omeprazol
Paracetamol
Not use it
There is not evidence of fetal risk
There is not evidence of fetal risk
Old people
Again and chronic conditions
contribuyed to
Limitation in responses to stress in the elderly
and management of pain
Carefull evaluation of conditions as imperative to pain management
Assessment of effectiveness and ADR
Physiological alteration in body composition and renal and hepatic funtion
alter
Distribuition and elimination of medications and metabolites
Non-medical treatments
● May be effective in managing pain
● Should be considered for older patiens
Childrens
Acetylsalicylic acid
Risks
Not use it
Reye Sindrom
Metabolic acidosis (<1 year old)
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?
CARBAMAZEPINE
Should you have any precaution whit this?
WEBSITES
 http://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.