1. PAIN MANAGEMENT MERCHÁN CUENDA, MERCEDES
MILÁN RODRIGUEZ, MARÍA MILAGROS
MORENO MARÍN, EDUARDO
NEVADO VILLAFRUELA, MARINA
MUÑOZ GARRIDO, JESÚS ÁNGEL

2. Acute Pain Management

3. Acute Gastritis - Omeprazole. Clarithromycin: 500 mg PO bid/tid.
Pain treatment Analgesics
Etiological treatment
- Omeprazole.
Clarithromycin: 500 mg PO bid/tid.
Amoxicillin: 500 mg PO qid.
No specific therapy exists for acute gastritis, except for cases caused by
H pylori.
OCA : 14 DIAS

4. Drug Dose Side effects Antacids H2 Blockers Proton pump inhibitors
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

5. 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

6. 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 administration (3-5min)
Pethidine
mg IV.
Drowsiness
Respiratory depression
Constipation
Very slow administration

7. Back pain First-line therapy NSAIDs Second-line therapy Opioids
Ibuprofen:
PO mg/d q6-8h(600mg/6h).
Naproxen:
PO mg/d. Initial dose: 550mg, followed 275mg q6-8h.
Second-line therapy
Opioids

8. Dysmenorrhea First-line therapy NSAIDs Prophylaxis
Ibuprofen:
400 mg PO q4-6h; not to exceed 3.2 g/d.
Naproxen:
PO mg/d. Initial dose: 550mg, followed 275mg q6-8h.
Prophylaxis
Oral Contraceptives Pill

9. Tension headache Metamizol Diazepam Metoclopra-mide 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
Metoclopra-mide
15 to mg/d PO divided in 2-4 times. Max dose: 0.5 mg/kg/d.
Extrapyramidal effects

10. Chronic Pain

11. Pain caused by lesion or dysfunction of the somatosensory system
NEUROPATHIC PAIN
Pain caused by lesion or dysfunction of the somatosensory system
The most common causes are:
Diabetes mellitus
Post-herpetic neuralgia
Trigeminal neuralgia
Cancer
NON-CANCER PAIN
CANCER PAIN

12. AMITRIPTYLINE, IMIPRAMINE, NORTRIPTYLINE
Effective doses 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.
1. FIRST-LINE TREATMENT:
Tricyclic antidepressants:
AMITRIPTYLINE, IMIPRAMINE, NORTRIPTYLINE
2. SECOND-LINE:
Anticonvulsivants:
PREGABALIN, GABAPENTIN
-SNRIs: VENLAFAXINET
-OPIOIDS: OXYCODONE, METHADONE, MORPHINE
-TRAMADOL
3. THIRD-LINE TREATMEN:
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.

13. 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

14. Trigeminal neuralgia CARBAMAZEPINE
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: oo mg OD
starting at 100mg bid
Habitual doses: 200 mg/day tid
It can increase in 100-2oo mg in two weeks.

15. Pain in Diabetic neurophaty
First-line agents:
Duloxetine (SNRIs)
Pregabalin
TCAs: amitriptylin
Second-line agents:
Gabapentin : mg/d
Lamotrigine: 400 mg/d
Venlafaxine: 150 to 225 mg
Tramadol: mg/d
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!!

16. 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.

17. 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!!
Improve relieve and pain but not insomnia
Relieve insomnia and pain but not depression

18. Fibromyalgia management
TRAMADOL, NSAIDs
PAIN
PREGABALIN
DULOXETIN
INSOMNIA
DEPRESSION

19. 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.

20. Medication is the most popular way to manage osteoporosis pain.
1.Pain medications:
Ibuprofen (NSAIDS)
Osteoporosis
2.Heat and ice:
Warm showers or hot packs

21. 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.

22. 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
Migraine
For best results, take pain-relieving drugs as soon as you experience symptoms of a migraine.
It may help if you rest or sleep in a dark room after taking them:

23. Pregnancy and Lactation
Metamizol
Not use it
Ibuprofen
Not use it
Naproxen
Not use it
Metroclopramide
Contraindication in lactation
Diazepam
Not use it
Oral contraceptives pills
Not use it
Omeprazol
There is not evidence of fetal risk
Paracetamol
There is not evidence of fetal risk

24. Old people Again and chronic conditions
Limitation in responses to stress in the elderly
and management of pain
contribuyed to
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
Non-medical treatments
● May be effective in managing pain
● Should be considered for older patiens

25. Childrens Acetylsalicylic acid Not use it Risks Reye Sindrom
Metabolic acidosis (<1 year old)

26. 35-year-old man come to urgency with acute renal colic pain
35-year-old man come to urgency with acute renal colic pain. What would you do?
First-line therapy Metamizol
Second-line therapy Pethidine

27. What treatment would you prescribe for a severe migrain?
A)NSAIDS
B)TRIPTANS

28. 26-year-old woman with moderate acute pain during menstruation.
¿What is the first-line therapy?
NSAIDs Ibuprofen or Naproxen

29. What drug do you prescribe to treat a trigeminal neuralgia?
CARBAMAZEPINE
Should you have any precaution whit this?

30. WEBSITES http://www.ncbi.nlm.nih.gov/pubmed/ http://content.nejm.org/

31. References:
Engeler DS et al. The ideal analgesic treatment for acute renal colic--theory and practice. 2008;42(2):
Prasad S et al. Use anesthetic drops to relieve acute otitis media pain Jan;93(1):40-4.
St. Onge et al. Pain Associated with Diabetic Peripheral Neuropathy. A Review of Available Treatments Mar;33(3): March.
Tomasz Podolecki et al. Fibromyalgia: pathogenetic, diagnostic and therapeutic concerns Mar;119(3):