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Arthritis Medication                                  See also   Muscle Relaxants

NSAID Nonsteroidal Anti-inflammatory Drugs

  • Aspirin 325 mg 2-3 tab tid
  • Disalcid (Salsalate) 500-750 mg 2 tab bid
  • Ansaid (Flurbiprofen) 50 100 mg tablet. Dose 50 mg 3 4x/d upto 100 mg tid
  • Arthrotec 50 or 75 (50 or 75 mg Diclofenac-Voltaren/ 200 mg Cytotec) 2-3x/day
  • Cataflam (Diclofenac-Voltaren) 50 mg tid
  • Clinoril (Sulindac) 150 200 mg tab. Dose 150 200 mg bid
  • Colchicine 0.6 mg q 1-2 hours  (Max 8-10 mg/day).  Off  if diarrhea occurs.
  • Daypro (Oxaprozin) 600 mg cap bid
  • Disalcid (Salsalate) 500-750 mg 2 tab bid
  • Dolobid (Diflunisal) 250-500 mg bid
  • Feledene (Piroxicam) 20 mg/day
  • Indocin (Indomethacin) 25-50 mg tid
  • Lodine (Etodolac) 200 300 mg capsules. Dose 200 400 mg q6 8h (not to exceed 1200 mg/d) for acute pain. 600
    1200 mg/d in divided doses (200 300 mg 2 4x/d)
  • Meloxicam (Mobic) 7.5 mg daily
  • Motrin (Ibuprofen) 200-400-600-800 mg tab tid pc
  • Nalfon (Fenoprofen) 300-600 mg qid
  • Naprosyn (Naproxen) 375 -500 mg tablets. Dose 375 -500 mg bid
  • Orudis (Ketoprofen) 50 75 mg capsules. Dose Start 75 mg tid or 50 mg qid (range 150 300 mg/d)
  • Oruvail (Keotoprofen-Orudis) 200 cap once/day
  • Tolectin (Tolmetin) 400-600 mg tid
  • Relafen (Nabumetone) 500 750 mg tab. Dose Start 500 mg 2 tab once/day, may be up to 200 mg/day
  • Voltaren (Diclofenac Na) 25, 50, 75 mg tablets 2-3x/day, or Voltaren-XR 100 mg tab/day

NSAID Group
*Proprionic acids group: ibuprofen (Motrin, Advil), naproxen (Naprosyn), fenoprofen (Nalfon), ketoprofen (Orudis), oxaprozin (Daypro), Ansaid (Flurbiprofen)
*Salicyclic acids group: indomethacin (Indocin), sulindac (Clinoril), diclofenac (Voltaren), etodolac (Lodine), Ketorolac, tolmetin (Tolectin)
*Oxicam group: piroxicam (Feldene)
*Anthranilic acids group: meclofenamate, mefenamic acid
*Naphthylakanone group: nabumetone (Relafen)
*COX-2 (Cyclo-oxygenase Inhibitor) specific or selective group: celecoxib (Celebrex), rofecoxib (Vioxx)

  

COX-2 Selective Inhibitors:


  

Muscle Relaxants
Flexeril (Cyclobenzaprine) 10 mg tid
Norgesic Forte ( Orphenadrine 50 mg & ASA 770 mg & Caffeine 60 mg) 3-4x/day
Parafon Forte (Chlorzoxazone 500 mg) qid
Robaxin (Methocarbamol) 500-750 mg 1-2x/day
Robaxisal (Methocarbamol 400 & ASA 325 mg) 2 tab qid
Soma (Carisoprodol) 350 mg tid & hs
Skelaxin (Metaxalone) 800 mg 3-4x/day   Do not administer with food.

  

World Health Organization analgesic ladder: effective in 70%–100% of adult patients
  1. Step One: for mild pain
    - NSAIDs and acetaminophen
  2. Step Two: for mild to moderate pain
    - Weak opioids (e.g., codeine, hydrocodone)
    - Combination analgesics (e.g., oxycodone/acetaminophen) plus NSAID and adjuvants as needed
  3. Step Three: for severe pain
    - Potent opioids (e.g., morphine, methadone, hydromorphone, fentanyl) plus NSAID and adjuvants as needed

Use adjuvant medications at any level of the WHO ladder

  • Corticosteroids (the most widely used adjuvants)
  • Antidepressants, anticonvulsants, and other agents for neuropathic pain
  • Bisphosphonates and radionuclides for bone pain
  • Antibiotics for pain from ulcerating tumors

Nonpharmacologic adjuvant therapy

  • External-beam radiation
  • Neurosurgical ablative procedures
  • Psychiatric therapy
  • Anesthesia

Opioids                                    See also constipation_rx.pdf
  • Indications
    • Acute pain
    • Trauma-related pain
    • Postoperative pain
    • Cancer pain
    • Some chronic noncancer pain (e.g., osteoarthritis, low back pain, neuropathic pain)
  • Choice of agent
    • Based on drug and patient characteristics
    • Morphine plus gabapentin may be more effective for neuropathic pain than either agent alone
    • Failure of response to an adequate trial of one opioid should be followed by an adequate trial of another opioid
  • Administration
    • Oral or transdermal
      • For systemic treatment of chronic conditions if possible
    • Intravenous
      • Rapid titration and onset of analgesia
      • Avoids first-pass hepatic degradation
      • Yields higher bioavailability and opportunity to reduce total dose
      • May provide consistent level of analgesia
      • Useful alternative for patients unable to take orally
      • Increased risk of systemic side effects
    • Subcutaneous injection
      • When small fluid volumes sufficient to deliver prescribed dose
      • Rapid titration and onset of analgesia
      • Shortened duration of effect requires continuous infusion or frequent redosing to maintain constant pain relief
      • Risk of side effects is greater than with oral route
    • Rectal
      • Absorption and first-pass metabolism varies
      • Cannot be used in patients with diarrhea, transmucosal lesions, neutropenia, or severe thrombocytopenia
    • Transdermal
      • When oral route is unavailable
      • Limited by available skin surface
      • Not effective for fluctuating pain levels
    • Intramuscular: avoid because of erratic absorption and associated pain
    • Patient-controlled analgesia (PCA)
      • For initiation of parenteral opioid therapy, rapid opioid titration, or treatment of incident pain
      • Continuous infusion may be programmed to supplement PCA doses, enabling sleep and covering baseline pain
      • Equivalent or superior analgesia with the following advantages:
        • Less total opioid consumption
        • Fewer side effects
        • No greater likelihood of dependence
        • May be used in the home
    • Intraspinal
      • For patients requiring large doses
      • Only for patients who have had pain relief but intolerable side effects with other regimens
      • Achieves analgesia at significantly smaller doses than with systemic administration
      • Intrathecal morphine is 100 times more potent than I.V.
      • Epidural morphine is 10 times more potent than I.V.
  • Dosing
    • Begin with immediate-release oral agent with a short half-life for 24–48 hr and monitor consumption, efficacy of pain relief, and side effects
      • Patients in severe pain may need rapid titration of a potent opioid via continuous I.V. infusion
    • Long-acting or sustained-release forms may be prescribed once titration to optimal dose is achieved
    • Change doses in increments of one third to one half the prior dose
    • Reduce or eliminate dose gradually (in increments < 25% of daily dose) if patient becomes pain free
    • Short-acting, immediate-release opioids to cover breakthrough pain for patients on long-acting therapy
      • Single rescue doses of 10%–20% of total daily dose or 25%–30% of single standing dose
      • Adjusted as appropriate for the individual
      • Where possible, use the same agent for standing and breakthrough medications
  • Conversion
    • Inflammatory or neuropathic pain may be better treated with adjuvant analgesics than with modification of opioid therapy
    • Pain of opioid side effects may only need treatment of the adverse effect
    • Refractory pain or intolerable side effects may require conversion in these settings:
      • Pain is opioid responsive
      • Current drug was titrated to maximal effect
      • Side effects are already optimally managed
    • Choice of opioids may be based on patient's past experience with opioids of a given class or receptor profile
    • Equianalgesic conversion tables should be consulted to arrive at a starting point for dosing
    • If patient is receiving multiple opioids, conversion should be based on total dose of all prior agents, expressed as morphine equivalents
    • If conversion is prompted by intolerable side effects but pain control is adequate, the calculated dose should next be reduced by ~ 25%–50%
    • If conversion is prompted by inadequate analgesia, the new agent may be started at or near an equianalgesic dose
    • Provide additional short-acting opioids during titration of new drug for breakthrough pain
    • Reassess pain and total daily dose for the first 2 wk after conversion, with titration of extended-release and breakthrough doses as appropriate
    • Avoid inadequate pain control and excessive narcosis during conversion
  • Side effects
    • Sedation
      • Occurs with onset of therapy or increase in dose; usually resolves within 3–7 days
      • Of concern in the elderly and those taking concurrent sedating medications
      • Eliminate nonessential sedating medications
      • Use stimulants (e.g., caffeine, methylphenidate) for cancer patients with significant persistent sedation
        • Use with caution in the elderly
        • Not recommended for patients with sedation due to opioid management of chronic pain
    • Nausea
      • Frequently resolves shortly after treatment onset
      • Antiemetics during first 1–2 days of opioids may help
        • Ondansetron, 4 mg I.V.
        • Prochlorperazine, 5–10 mg t.i.d.–q.i.d.
        • Hydroxyzine
          • May alleviate centrally induced nausea
          • Dose: 25–100 mg t.i.d.–q.i.d.
        • Metoclopramide
          • May reduce nausea caused by slowed gastric motility
          • Dose: 10 mg q.i.d.; maximum daily dose, 500 µl/kg
        • Scopolamine
          • May alleviate motion-exacerbated nausea in ambulatory patients
          • Dose: transdermal, 1.5 mg postauricular patch q. 3 days
          • May have significant anticholinergic side effects, particularly in the elderly
    • Constipation
      • Does not improve with time
      • Often underdiagnosed
      • May lead to anorexia, vomiting, abdominal pain, obstruction, impaction, and perforation
      • Appropriate dietary changes
      • Assess for constipation in patients on around-the-clock opioids
      • Stool softeners and stimulant laxatives
    • Respiratory depression
      • Rare side effect in opioid-naive patients receiving large doses and in head injury or pulmonary disease
      • Monitor sedation level and respiratory status during first 24 hr of therapy in opioid-naive patients
      • Stop opioids until depression resolves, then resume at 75% of previous dose
      • Spirometry and oxygen may be useful
      • Treat severe respiratory depression with I.V. naloxone
        • Dose: 2 mg I.V. in 500 ml normal saline or D5W
    • Confusion
      • Occurs primarily in high-dose or prolonged opioid therapy and in decreased renal function
      • Patients with previous cognitive impairment at additional risk
      • Symptoms include delirium, agitation, myoclonus, hyperalgesia
      • Of particular concern in the elderly or those with concurrent CNS disease
      • Nonessential medications with CNS effects should not be prescribed for elderly patients requiring opioid therapy
      • Neuroleptics may be useful against confusion, mental clouding, or persistent delirium
    • Pruritus
      • Diphenhydramine, 25–50 mg q. 4–6 hr
      • Hydroxyzine, 25–100 mg t.i.d.–q.i.d.
    • Myoclonus
      • Clonazepam, 0.5 mg t.i.d.; increase by 0.5–1 mg q. 3 days to maximum of 20 mg/day
  • Tolerance
    • A higher dose of agent is required to maintain a given effect
    • There is no clinical limit to tolerance
    • Rarely develops in stable disease
    • Increasing requirements for previously controlled chronic pain should prompt comprehensive evaluation
  • Physical dependence
    • A withdrawal syndrome could be produced by the following:
      • Abrupt cessation of drug administration
      • Rapid reduction in dose
      • Decreasing blood level of drug
      • Administration of an antagonist or mixed agonist-antagonist
    • Universal with prolonged opioid therapy
    • To avoid withdrawal, all patients receiving opioids for e 1 wk should have drug tapered rather than abruptly discontinued
  • Psychological dependence (addiction)
    • Differentiate from physical dependence
    • Impaired control over drug use, compulsive use, continued use despite harm, and craving
    • Extremely low prevalence in patients taking opioids for pain relief
    • Pseudoaddiction
      • More common than true addiction
      • Patients with poorly managed pain mimic signs of psychological dependence
        • Drug seeking
        • Increased focus on obtaining medications
        • Possibly illicit drug use or deception
      • Behaviors resolve with effective pain management
      • May be exacerbated by curtailing of opioid therapy

  

NSAIDs and Acetaminophen
  • No tolerance or physical dependence
  • Indications
    • Especially useful for muscle and joint, bone, dental, postoperative, and inflammatory pain
    • May suffice for mild or moderate pain
    • For severe pain, may be added to an opioid regimen for opioid-sparing effect and enhanced pain relief
  • Ceiling effect for analgesia
  • NSAID side effects
    • GI symptoms
    • GI bleeding
    • Hypersensitivity
    • Kidney dysfunction
    • CNS effects
    • Often dose dependent
  • NSAIDs may be used with GI-protective drugs
  • Use acetaminophen with caution in patients with liver disease

 

Corticosteroids
  • Indications
    • Cancer pain
      • Pain of spinal cord compression
      • Increased intracranial pressure
      • Superior vena cava syndrome
      • Metastatic bone pain
      • Neuropathic pain secondary to infiltration or compression by tumor
      • Hepatic capsule distention
    • High doses for inpatients with advanced disease in acute pain crisis
    • Pain related to musculoskeletal conditions
  • Oral or injectable
  • Side effects
    • Well tolerated for short-term treatment
    • Toxicities
      • Often arise with prolonged high-dose therapy
      • Adrenocortical insufficiency
      • Hypertension
      • Immune suppression, masking of signs of infection
      • Glaucoma
      • Electrolyte imbalances
      • GI ulceration and/or bleeding
      • Osteoporosis and/or pathologic fracture
      • Psychiatric disturbance or psychosis
    • Avoid withdrawal syndrome upon discontinuance

 

Antiepileptic Drugs
  • Indications
    • Adjuvants for neuropathic pain
      • Peripheral diabetic neuropathy
      • Postherpetic neuralgia
      • Reflex sympathetic dystrophy
      • Trigeminal and glossopharyngeal neuralgia
      • HIV neuropathy
      • Spinal cord injury–related dysesthesias
    • Postlaminectomy pain
    • Phantom limb pain
    • Cancer pain
  • Gabapentin (Neurontin):  first-line treatment for neuropathic pain
    • Well tolerated (except for cognitive effects in the elderly)
    • Side effects: sedation, nausea/vomiting, dizziness
    • Dose: 100 mg p.o., q. 8 hr (maximum, 3,600 mg/day in divided doses)
  • Carbamazepine (Tegretol)
    • First-line treatment for trigeminal neuralgia
    • Second- or third-line agent for other neuropathic pain conditions
    • Dose: 50–60 mg/day
    • Monitor for hyponatremia and leukopenia
    • Use only if gabapentin has failed or is not tolerated
    • May cause thrombocytopenia or liver damage
  • Topiramate (Topamax): adjuvant analgesic for neuropathic pain
    • Dose: 100–200 mg/day
    • Must be titrated slowly (no faster than 25 mg/wk) to decrease side effects such as cognitive slowing and paresthesias

   

Tricyclic Antidepressants (TCAs)
  • Indications
    • Adjuvants for neuropathic pain
      • Painful diabetic neuropathy
      • Postherpetic neuralgia
      • Chronic facial pain
      • Central pain
    • Adjuvants for chronic pain
      • Cancer pain
      • Chronic low back pain
      • Osteoarthritis
  • Efficacy: comparable to antiepileptics
  • Amitriptyline (Elavil): alternate choice
    • Strongest anticholinergic profile
    • Given at bedtime
  • Nortriptyline (Pamelor): alternate choice
    • Less anticholinergic effect
    • Better choice for older patients
  • Imipramine (Tofranil): alternate choice
  • Dose for TCAs: 10–25 mg, to maximum of 150 mg/day, if tolerated
  • Side effects of TCAs: elderly are most susceptible
    • Sedation
    • Hypotension
    • Constipation
    • Urinary retention
    • May cause lethal cardiac arrhythmias at very high doses (contraindicated in patients with conduction abnormalities)

 

Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Useful in managing neuropathic pain
  • Second-line choice for refractoriness or poor tolerability with other agents
  • Paroxetine (Paxil)
    • Dose: 20–50 mg/day
  • Venlafaxine (Effexor)  
    • Dose: 37.5–225 mg/day

 


          

2006