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Analgesics
 

Analgesics

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    Analgesics Analgesics Presentation Transcript

      • GOOD MORNING
    • Department Of Oral Medicine & Radiology PRESENTED BY: NEHA KAPOOR ROLL NO. 32 4th batch
    • SEMINAR ON ANALGESICS USED IN DENTISTRY
    • CONTENTS
      • Introduction
      • Classification
      • NSAIDs
      • References
    • INTRODUCTION
      • ANALGESICS
      • A drug that selectively relieves pain by acting in CNS or on peripheral pain mechanism, without significantly altering consciousness.
      • ANAESTHESIA
      • Anaesthesia means loss of sensation. Anaesthetic agent is one which bring about loss of all modalities of sensation, particularly pain, along with a reversible loss of consciousness.
      • PAIN (ALGESIA)
      • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
      • -IASP
    • OROFACIAL PAIN
      • NOCICEPTIVE PAIN
      • ( tissue injury and inflammation)
      • Odontogenic conditions
      • Eg. Pulpitis,apical periodontitis.
      • Mucosal conditions
      • Eg. Ulcers,lichen planus,herpes simplex
      • Musculo skeletal conditions
      • Eg. Myofacial pain,temporo mandibular joint capsulitis,arthritis.
      • NEUROPATHIC PAIN
      • ( primary lesion or dysfunction of nervous system)
      • Classic cranial neuralgias
      • Eg. Trigeminal and glossopharygeal
      • Stomatodynia
      • Phantom tooth pain
      • Traumatic nerve injuries
    • CLASSIFICATION
      • Divided into 2 groups:
      • 1. Opioid Analgesics -Narcotics/Morphine like analgesics
      • 2. Non Opioid Analgesics -NSAIDs/Non narcotic/aspirin like analgesics
    • OPIOID ANALGESICS
      • Natural Opium alkaloids
      • - Morphine & Codeine.
      • Semi synthetic opiates
      • Diacetylmorphine
      • oxymorphone
      • - Pholcodeine
      • Synthetic opioids
      • Pethidine
      • Fentanyl
      • Methadone
      • Dextropropoxyphene
      • Ethoheptazine
      • Tramadol
    • NON OPIOID ANALGESICS & NSAIDs
      • Analgesic and Anti inflammatory
      • NON-SELECTIVE COX INHIBITORS
      • Salicylates – Aspirin, Salicylamide, Benorylate, Diflunisal.
      • Pyrazolone derivatives – Phenyl butazone, Oxyphenyl-butazone.
      • Propionic acid derivatives – Ibuprofen, Naproxen, Ketoprofen, Fenoprofen, Flurbiprofen, Oxaprozin.
      • Indole derivatives – Indomethacin, Sulindac.
      • Anthranilic acid derivative – Mephanimic acid, Flufenamic acid.
      • Aryl acetic acid derivative – Diclofenac, Tolmetin..
      • Oxicam derivative – Piroxicam, Tenoxicam.
      • Pyrrolo pyrrole derivatives – Ketorolac, Feprazone.
      • B. Prefential COX-2 inhibitors
      • - Nimesulide
      • - Meloxicam
      • - Nabumetone
      • C. Selective COX-2 inhibitors
      • - Valdecoxib
      • - Celecoxib
      • - Rofecoxib
      • D. Analgesics with poor Anti inflammatory action-
      • Paraminophenol derivative
      • - Paracetamol (Acetaminophen)
      • Pyrazolone derivative
      • - Metamizol, Propiphenazone
      • Benzoxazocine derivative
      • - Nefopam
    • MECHANISM OF ACTION OF NSAIDS
      • Prostaglandins synthesis inhibiton
      • Membrane phospholipids
      Phospholipase A Arachidonic acid Cyclo oxygenase PG G 2 + PG H 2 Isomerases Thromboxane sythetase Prostacyclin synthetase PG E 2 , PG D 2 , PG F TX A2 TX B 2 PG I 2 PG E 2 , PG D 2 , PG F TX A 2
    • ASPIRIN
      • Acetylsalicylic acid
      • Pharmacological actions
      • Analgesic, antipyretic, antiinflammatory actions
      • Metabolic effects: Blood sugar may decrease, plasma free fatty acid & cholesterol levels reduced
      • Respiration: Hyperventilation in salicylate poisoning
      • Acid base & electrolyte balance: Compensated respiratory alkalosis
      • CVS: Vasodilation, increase in cardiac output
      • GIT: Epigastric distress, nausea & vomiting
      • Blood: Prolongs bleeding time
      • ADVERSE EFFECTS :
      • Nausea, vomiting, epigastric distress, increased blood loss in stools
      • Rashes, fixed drug eruptions, urticaria, rhinorrhea, angioedema, asthma, anaphylactoid reaction
      • Salicylism – dizziness, tinnitus, vertigo, impairment of hearing & vision, excitement & mental confusion, hyperventilation & electrolyte imbalance
      • Acute salicylate poisoning: Fatal dose in adults 15-30g, lower in children
      • USES :
      • Analgesic
      • Antipyretic
      • Acute rheumatic fever
      • Rheumatoid arthritis
      • Osteoarthritis
      • Postmyocardial infarction
      • Patent Ductus Arteriosus
      • Familial colonic polyposis
      • Prevention of colon cancer
      • Treatment of Bartter’s syndrome
      • Precautions & Contraindications :
      • Peptic ulcer
      • Bleeding tendencies
      • Children with chicken pox or influenza
      • Chronic liver disease
      • Diabetics
      • Pregnancy
      • Breast feeding mothers
      • G6 PD deficient individuals : Hemolysis
      • Dose
      • - 0.3-0.6 g 4-6 hrly orally
      • Commercially available as:
      • Aspirin : 350 mg tab.
      • Disprin: 350mg tab.
      • Colsprin: 100, 325,650mg tab.
      • Ecosprin: 75, 150, 325mg tab.
    • Dental consideration in a patient who is on aspirin therapy
      • BT
      • CT
      • PT
      • INR
    • INDOMETHACIN
      • Indole derivative
      • Potent inhibitor of PG synthesis & suppresses neutrophil motility
      • Well absorbed orally & t ½ is 2-5 hrs
      • Adverse effects: Gastric irritation, nausea, anorexia, gastric bleeding & diarrhoea, frontal headache, dizziness, ataxia, mental confusion, depression, psychosis, leukopenia, rashes, increased risk of bleeding
      • Contraindicated in machinery operators, drivers, psychiatric patients, epileptics, kidney disease, pregnant women & children
      • Dose: 25-50mg BD-QID
      • Commercially available as-
      • Idicin, Indocap, Indoflam : 25mg, 75mg tab
    • IBUPROFEN
      • Propionic acid derivative
      • Adverse effects:
      • Gastric discomfort, nausea & vomiting
      • Headache, dizziness, blurring of vision, tinnitus & depression
      • Avoided in pregnancy, peptic ulcer patient & asthmatic patients
      • USES:
      • Analgesic & Antipyretic
      • Rheumatoid arthritis, osteoarthritis, musculoskeletal disorders
      • Soft tissue injuries, fractures, vasectomy, tooth extraction
      • Postpartum & postoperatively : suppress swelling & inflammation
      • Dose: 400-800 mg TDS
      • Comercially available as-
      • Brufen, Emflam, Ibusynth : 200, 400, 600mg tab.
      • Ibugesic : 100mg, 400 mg tab.
    • MEPHENAMIC ACID
      • Anthranilic acid derivative
      • Adverse effect: Diarrhoea, skin rashes, dizziness & other CNS manifestation
      • Orally absorbed & t ½ is 2-4 hrs
      • Uses: Analgesic in muscle, joint & soft tissue pain, dysmenorrhoea, rheumatoid & osteoarthritis
      • Dose: 250-500 mg TDS
      • Commercially available as:
      • Medol, Meftal - 250, 500 mg tab.
    • DICLOFENAC SODIUM
      • Aryl-acetic acid derivative
      • Well absorbed orally
      • Plasma t ½ - 2 hrs
      • Adverse effects: Epigastric pain, nausea, headache, dizziness, rashes
      • Uses: Rheumatoid arthritis, ankylosing spondylitis, dysmenorrhea, post traumatic & post inflammatory conditions
      • Dose: 50mg TDS, then BD oral, 75mg deep i.m
      • Commercially available as:
      • Voveran, Diclonac, Movonac : 50 mg tab.
      • Diclomax : 25, 50 mg tab.
    • PIROXICAM
      • Oxicam derivative
      • Long acting potent NSAID
      • Good analgesic-antipyretic action
      • Metabolised in liver ; excreted in urine & bile
      • Plasma t ½ is 2 days
      • Side effects : heart burn, nausea & anorexia
      • Use as short term analgesic & long term anti inflammatory drug – rheumatoid & osteo arthritis, ankylosing spondylitis, acute gout, musculoskeletal injuries,dysmenorrhoea etc
      • Dose: 20mg BD for 2 days followed by 20mg OD
      • Commercially available as-
      • Dolonex, Pirox, Piricam : 10, 20 mg cap.
    • KETOROLAC
      • Pyrrolo-pyrrole derivative
      • Potent analgesic & modest anti inflammatory
      • Rapidly absorbed after oral & i.m administration
      • Plasma t ½ is 5-7 hrs
      • Adverse effects: Nausea, abdominal pain, dyspepsia, ulceration, loose stools, drowsiness, headache, dizziness, nervousness, pruritis, pain & fluid retention
      • Not be given to patients on anticoagulants
      • USES:
      • Postoperative & acute musculoskeletal pain: 15-30 mg i.m or i.v every 4-6 hrs
      • Used for renal colic, migraine, pain due to bony metastasis
      • Orally in a dose of 10-20 mg 6 hrly.
      • Commercially available as –
      • Ketorol, Zorovon, Ketanov, Torolac : 10mg tab.
    • NIMESULIDE
      • Preferential COX-2 inhibitors
      • Used for short lasting painful inflammatory conditions like sports injuries, sinusitis, ear nose throat disorders, dental surgery, bursitis, low backache, dysmenorrhoea, post operative pain, osteoarthritis & for fever
      • Completely absorbed orally, excreted in urine, t ½ of 2-5 hrs
      • Adverse effects:
      • - Epigastralgia, heart burn, nausea, loose motions, rash pruritus.
      • - Hematuria & fulminant hepatic failure in few cases
      • Useful in asthmatics, bronchospasm or intolerance to aspirin & other NSAIDs
      • Dose: 100 mg BD
      • Commercially available as-
      • Nimulid, Nimegesic, Nise, Nobel, Nimodol : 100mg tab.
    • ROFECOXIB
      • Selective COX-2 inhibitor.
      • Effective in osteoarthritis, rheumatoid arthritis, dysmenorrhoea, dental, post operative & acute musculoskeletal pain at dose of 12.5-25 mg OD daily
      • Side effects mild g.i complaints, headache & dizziness
      • Well absorbed orally & t ½ of 17 hrs
      • Avoided in presence of severe hepatic or renal disease
      • Dose: 12.5-25 mg OD
      • Commercially available as-
      • Rofact, Rofegesic, Rofibax : 12.5, 25 mg tab.
    • PARACETAMOL
      • Para-amino phenol derivative
      • Actions: Good & promptly acting antipyretic
      • Well absorbed orally
      • Plasma t ½ is 2-3 hrs
      • Safe & well tolerated
      • Nausea & rashes occur occasionally
      • Analgesic nephropathy- years of heavy ingestion
      • Acute paracetamol poisoning:
      • - In small children with glucuronide conjugating ability
      • Nausea, vomiting, abdominal pain, liver tenderness
      • Centrilobular hepatic necrosis accompanied by renal tubular necrosis & hypoglycemia, may progress to coma
      • Jaundice after 2 days
      • Treatment: Vomiting induced, activated charcoal given, N-acetylcystein 150mg/kg infused iv over 20hrs, alternatively, 75mg/kg orally every 4-6 hrs for 2-3 days.
      • USES:
      • First choice analgesic for osteoarthritis
      • Best drug to be used as antipyretic
      • Over the counter analgesic for headache, musculoskeletal pain, dysmenorrhoea, etc
      • Much safer than aspirin
      • Does not prolong bleeding time
      • Used in all age groups, pregnant & lactating women, in other disease states & in patients in whom aspirin is contraindicated
      • No significant drug interactions
      • DOSE:
      • 0.5-1g TDS;
      • infants 50mg;
      • children 1-3 yrs 80-160mg
      • 4-8 yrs 240-320mg
      • 9-12 yrs 300-600mg
      • Commercially available as-
      • Crocin : 0.5, 1 gm tab.
      • Ultragin, Pyrigesic, Calpol : 500mg. tab
    • SYNERGISTIC EFFECT
      • When the action of one drug is facilitated or increased by the other, they are said to be synergistic.
      • ADDITIVE SYNERGISM
      • Combiflam : ibuprofen+ paracetamol (400 + 325mg)
      • Dolokind plus : aceclofenac + paracetamol (100 +500 mg)
      • Diclozee plus : diclofenac Na + acetoaminophen (50 + 500 mg)
      • Diclomol : diclofenac Na + acetoaminophen (50 + 500 mg)
      • Serazee plus : diclofenac K + seratiopeptidase (50 +10 mg)
      • Ibugesic plus : ibuprofen+ paracetamol (400 + 325mg)
      • Asonac-SR plus : aceclofenac + paracetamol + seratiopeptidase (100 + 500 + 15mg )
    • TOPICAL NSAIDs
      • Topical formulations are available for application over painful joints and muscles.
      • Osteoarthritis
      • Sprains
      • Sports injuries
      • Backache
      • Preparations
      • Diclofenac 1% gel : voveron emulgel, diclonac gel.
      • Ibuprofen 10% gel : ribufen gel.
      • Ketoprofen 2.5% gel : rhofenid gel.
      • Nimesulide 1% gel : nimulid trans gel.
      • Piroxicam 0.5% gel : dolonex gel, minicam gel.
    • INDICATIONS OF NSAIDS IN DENTISTRY
      • Irreversible pulpitis
      • Apical periodontitis
      • Acute alveolar abscess
      • Infected cyst
      • Sinusitis
      • TMJ Arthritis
      • MPDS
      • After tooth extraction
      • Dry socket
      • Recurrent apthous ulcers
      • Lichen planus
      • Agranulocytosis
      • Cyclic neutropenia
    • GENERAL CONTRAINDICATIONS
      • Ulcer
      • Asthma
      • Patient with nasal polyp
      • Diabetes
      • Gout
      • Influenza (Reye’s syndrome)
      • Hypo coagulation state
      • Chronic allergic disorders
      • Chronic liver disease
      • Renal failure
      • Salicylate allergy
      • Breast feeding mothers
      • Pregnancy
    • CONCLUSION
      • Nature of problem along with consideration of risk factors in an individual patient directs the initial selection
      • Drugs differ quantitatively in producing different side effects
      • Large inter individual differences
    • REFERENCES
      • Essentials of Medical Pharmacology,
      • K. D Tripathy, 5 th edition
      • Pharmacology & Pharmacotherapeutics,
      • R. S. Satoskar,18 th edition
      • Textbook of oral medicine,
      • Burkett’s, 11 th edition
      • THANK YOU
      THANK YOU