Postop Pain Leal 09

1,410 views
1,335 views

Published on

Current concepts in postoperative pain management, by Prof. Dr. Carlos Leal MD - Bosque University Orthopedics - Bogota

Published in: Health & Medicine
1 Comment
7 Likes
Statistics
Notes
No Downloads
Views
Total views
1,410
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
1
Likes
7
Embeds 0
No embeds

No notes for slide
  • <number>
  • 24/05/09<number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • 17
  • <number>
  • <number>
  • INFLAMACION y DOLOR: principal causa de consulta m
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • Celebrex (Celecoxib): Vida media de 11,2 horas. Dosis de 100 a 200 mg / dia o Bid. Comienzo de la accion en 1 hora. Teratogenico. Metabolismo P 450. Quimicamente es una sulfonamida. Dosis equivalentes Vioxx Vs Celebra: 12.5 mg Vs 200. Dosis equipotentes 25 mg Vs 200 mg/bid.el acetaminofen, que a pesar de tener propiedades analgesicas y antipireticas similares a la de la aspirina no tiene propiedades antiinflamatorias importantes por lo que actualmente no se le considera como un AINE.<number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • <number>
  • Porque el dolor
  • <number>
  • La mayor
  • <number>
  • 1936: MYOCHRYSINE (sales de oro) para el tratamiento de la Artritis Reumatoide.1949: MSD desarrolla el primer corticoesteroide (CORTONE). 1952: Desarrollo de HYDROCORTONE , un sucesor m
  • <number>
  • <number>
  • 63
  • Modelos de analgesia aguda 120 mg una vez al d
  • Protocol 039, estudio fase III, Dolor dental POP, Arcoxia 120 mg,Naproxeno 550 mg acetaminofen-code
  • Protocolo 055, fase III, N=225 pacientes.COCNLUSIONES:Arcoxia 120 superior a placebo en todas la mediciones de analgesia, incluyendo el efecto analg
  • Estudio 057: Estudio fase III, N= 320 pacientes.CONCLUSIONES:Arcoxia 120 efecto general superior a oxicodona/acetaminof
  • <number>
  • Absorci
  • Metabolismo compartido entre varias sub-familias de CYP. No depende de una sola como otros medicamentos.Uni
  • Warfarina: Aumenta 13% el tiempo de protrombina. Rifampicina: Disminuyo 65% C de Arcoxia. Metotrexate: ↑28% C (dosis > 120 mg de Arcoxia). IECAS: AINES disminuyen efecto antihipertensivo. Litio: AINES aumentan los niveles plasmáticos de Litio. Anticonceptivos orales: Arcoxia 120 mg aumentó los niveles de etinilestradiol de 37% al 60% posiblemente al inhibirir con una enzima sulfotransferasa comprometida en la sulfatación de los estrogenos (sangrados vaginales, turgencia mamaria), en preparados con más de 35 mcg de EE y 0.5 a 1 mg de norethindrona. Al pensarse en una terapia de remplazo hormonal, debe tenerse en cuenta este incremento de la concentración estrogénica.<number>
  • Estos efectos secundarios son del programa general (no Medal):Otros efectos secundarios son sabor met
  • Estos efectos secundarios son del programa general (no Medal):Otros efectos secundarios son sabor met
  • El programa de seguridad de Arcoxia se dise
  • Una ventaja fundamental de los Coxibs sobre los AINEs convencionales es el menor potencial de producir eventos adversos GI, incluyendo
  • En teor
  • El riesgo cardiovascular de los “coxibs” es dosis dependiente y relativo al tiempo, por tanto se deben de usar a dosis mínimas efectivas y por el menor tiempo posible en pacientes en riesgo cardiovascular…..En pacientes con insuficiencia hep
  • <number>
  • Cuatro tipos de modelo de analgesia aguda: Dolor dental, dismenorrea primaria y pop Qx ortop
  • El programa incluy
  • Total pacientes estudiados en esta indicaci
  • Los estudios en patolog
  • <number>
  • Postop Pain Leal 09

    1. 1. Current Managem of ent Postoperative Pain Carlos Leal M.D. Director Orthopedic Research Laboratory Director of Knee Surgery & Sports Medicine Fellowship Bosque University Orthopedic Department Bogotá DC, Colombia
    2. 2. Pain is an unpleasent sensorial and em otional experience associated to a real or potential tissue dam age International Association for the study of Pain
    3. 3. The goals of effective and appropriate pain managem are to… ent  Im prove quality of life for the patient  Facilitate rapid recovery and return to full function  Reduce morbidity  Allowearly discharge from hospital
    4. 4. Effe c tive po s to pe rative pain manag e me nt has a humanitarian ro le , But the re are additio nal me dic al and e c o no mic be ne fits fo r rapid re c o ve ry and dis c harg e fro m ho s pital.
    5. 5. Effe c tive pain manag e me nt is no w an inte g ral part o f mo de rn s urg ic al prac tic e Postoperative pain management -m inim izes patient suffering - can reduce m orbidity - facilitates rapid recovery and early discharge from hospital - can reduce hospital costs
    6. 6. Pain Theories. • Specificity theory • Pattern theory • Gate control theory
    7. 7. INJURY GATE Various factors: physical, emotional, cognitive or behavioural open or close the gate PAIN experienced depending on howfar gate open or closed
    8. 8. Conditions that Open the Gate • Physical conditions Extent of injury Nature of injury • Emotional states Anxiety W orry Tension Depression • Cognitive states Focusing on the pain
    9. 9. Conditions that Open the Gate • Physical conditions Extent of injury Nature of injury • Emotional states Anxiety W orry Tension Depression • Cognitive states Focusing on the pain
    10. 10. Co nditio ns that Clo s e the Gate • Physical M edication Counterstim ulation (e.g. heat, massage) • Emotional state Positive em otions (e.g., happiness, optim ) ism Relaxation Rest • Mental state Intense concentration or distraction Involvem and interest in activities ent
    11. 11. GOOD PAIN… Acute pain plays a useful quot;positivequot; physiological role • Providing a warning of tissue dam age • Inducing im obilization m to allow appropriate healing
    12. 12. BAD PAIN…. S ho rt te rm ne g ative e ffe c ts o f ac ute pain  Emo tio nal and phys ic al s uffe ring fo r the patie nt  S le e p dis turbanc e w negative im ith pact on mood and mobilization  Cardio vas c ular s ide e ffe c ts such as hypertension and tachycardia
    13. 13. Pain as a Health Problem Characteristic Acute Pain Chronic Pain Type Somátic, viscera o referred Persistent/ low back pain Source Accute lesion Multifactorial or unknown Onset / Time Sudden / 6 months Slow / > 6 months Physiological High cardiac and respiratory Symilar to accute, but with Responses rate. High bood glucose. adaptation of blood presure, Decreased gastrointestinal heart rate. motion. Nausea. Blood flow redistribution Psicological Fear, anxiety and bad temper Depression, sleep pattern Responses changes, denial. Prognosis Full recovery Likely Full recovery not likely
    14. 14. MOST FREQUENT SCENARIOS Pain Inflam ation m Inflam ation m Pain Reumathoid Arthritis Osteoarthrosis Chronic Back Pain Postoperative Pain
    15. 15. MOST FREQUENT SCENARIOS Inflammation Pain Accute Gout
    16. 16. Pain Treatm Goals ent Reduce discapacity Improve quality of life Use safe m edications that reduce toxic effects Less Time
    17. 17. Our m frequent problem ost s Chronic Musculoskeletal Pain
    18. 18. Our m frequent problem ost s Postraumatic Pain Postoperative Pain
    19. 19. Postoperative Pain • Pain generates em otional, physiological and psicological responses that affect the final recovery • Intensity of pain depends on the operated area: Thorax –Thoracoabdom inal Abdom –Hip & Knee –OBGYN en Low Abdom er en Osteoarticular Skin
    20. 20. Postoperative Pain Adverse Effects Respiratory Cardiovascular Gastrointestinal Urinary Neuroendocrine M etabolic Psicological
    21. 21. Pain Evaluation • Measurem of self evaluation ent • VAS –Visual Analogue Scale • Numeric verbal score • Graphic scales score • Observational Measurements • Pain Observational Scale • Toddlers Pain Scale
    22. 22. Pain As s e s s me nt
    23. 23. Pain Treatment • Opioids –System ic –Subaracnoid –Epidural • Non Opioid Analgesics –NSAIDS –Local Anesthetics • Psicological Methods
    24. 24. IAS P Po s to p Pain Pro to c o ls International Association for the Study of Pain
    25. 25. S c ale Tre atme nt International Association for the study of Pain ty Ablatio n s urg e ry si n IV Mo rphine te In Te ns in Pa Ne rve /S pinal Blo c k Opio id de rivate s NS AIDS + Co de in NS AIDS As pirin Ac e tamino phe n
    26. 26. Opioids • Obtained from Opium –Poppy flow er (natural) • Also Synthetic or sem i-synthetic • Sem i-synthetic are based on m orphin or tebain
    27. 27. Opioids Natural Synthetic Morphine Levorfanol Codein Papaverin M etadone Tebain Pentazocine Phenilpiperidines Phentanil Sufentanil Meperidine Semisynthetic Heroín Dehidrom orfin Buprenorfin
    28. 28. Opioid Effects • CNS: Pow erful analesic action – Efective pain control – Eliminates em otional side • Respiratory: depression – Dose dependent – Decreases ventilatory response to CO2
    29. 29. Opioid Effects • Muscle: – Increase of muscle tone, dose dependent • Cardiovascular – lowm iocardial depresion – reduces peripheral vascular resistance – increases venous capacity – causes bradichardia
    30. 30. Opioid Effects • Sphincter contracture – Abdom inal pain – Urinary retention • Nausea & vomit • Increase of GI secretions • Myosis
    31. 31. Don’Forget… t • Patients m have perm ust anent m edical suport • Clearly specify dose and schedule • Keep record of adverse effects and com plications • Monitor frequency and depth of respiratory m ovem ents
    32. 32. No n Opio id Analg e s ic s NS AID S S alic ilat es Paraamino fe no ls
    33. 33. Salicilates • Sir John Robert Vane • 1982 Nobel Prize • Effects of Aspirin in Pain
    34. 34. Salicilates • Ciclooxigenase non reversible inhibition , interfering with prostaglandin synthesis • Aspirin is the prototype molecule • Effects: control of pain, fever and inflam ation m • M significative side effect: erosive gastritis and GI bleeding ost • Inhibits platelet function for 7 days • Com on hypersensitivity and alergic reactions m
    35. 35. Para-Amino- Phenols • Good pain and fever control • No anti-inflam atory effects m • No peripheral ciclooxigenase inhibition • M w ost idely used analgesic in the world • High doses or long lasting treatments m cause liver toxicity ay
    36. 36. NSAIDS Non Steroidal Pharm acologic Agents that act on Pain and Inflam ation Pathw m ays
    37. 37. Inflam ation m Represents the first step in tissue repair, when the chem ical mediators produce increased blood flow capillary , perm eability, coagulation, edem and a, cell m igration The s e e ffe c ts s timulate pain no c ic e pto rs pe rmane ntly
    38. 38. Pain and Inflam ation Pathw m ays Tissue Damage Pro-Inflammatory Response Araquidonic Acid COX Prostaglandins Pain Inflammation Fever
    39. 39. NSAID Actions M NSAIDs act as non-selective inhibitors ost of the ciclooxygenase, inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzym es Cyclooxygenase catalyzes the formation of prostaglandins and throm boxane from arachidonic acid Prostaglandins act (am ong other things) as messenger m olecules in the process of inflam ation. m
    40. 40. NSAID Facts - M NSAIDs are w ost eak acids, w a pKa of 3-5 ith -They are absorbed w from the ell stomach and intestinal m ucosa. - They are highly protein-bound in plasm (>95%) a
    41. 41. NSAID Facts - M NSAIDs are m ost etabolized in the liver by oxidation and conjugation to inactive m etabolites w hich are typically excreted in the urine, although som e drugs are partially excreted in bile. -M etabolism m be ay abnorm in certain disease al states, and accum ulation m occur even w norm ay ith al dosage.
    42. 42. NS AID Fac ts - Ibuprofen and Diclofenac have short half-lives (2– hours) 3 - Coxibs have an average half-life of 24 hours - Oxicam have very long half-lives s (20– hours) 60
    43. 43. NSAIDS by chemical family Propionic acids Heteroaril- Acetic Acids – Tolmentin – Ibuprofen – Ketorolac – Phenoprofen – Ketoprofen Phenilacetics – Phlurbiprofen – Diclofenac – Naproxen Indolacetic Acids – Oxaprozin – Indom ethacin – Sulindac Pirazolones – Etodolac – Phenilbutazone
    44. 44. NSAIDS Adverse Effects The widespread use of NSAIDs has m eant that the adverse effects of these relatively safe drugs have becom increasingly prevalent. e Gastrointestinal Renal Cardiovascular Other…
    45. 45. NSAIDS Adverse GI Effects -These effects are dose-dependent -In m any cases severe enough to pose the risk of - ulcer perforation / upper GI bleeding / death - An estimated 10-20% of NSAID patients experience dyspepsia
    46. 46. NSAIDS Adverse GI Effects -2008 FDA DATA - Estimated to result in 103,000 hospitalizations and 16,500 deaths per year in the US - Represents 43% of drug-related emergency visits -M any of these events are avoidable: - Unnecessary prescriptions for NSAIDs w were ritten in 42% of visits.
    47. 47. NS AIDS Cardio vas c ular Adve rs e Effe c ts Ke arne y e t al., BMJ 2006;332:1302–1308 A re c e nt me ta -analys is o f all trials c o mparing NS AIDs fo und an 80% inc re as e in the ris k o f myo c ardial infarc tio n with bo th ne we r COX-2 antag o nis ts and hig h do s e traditio nal anti- inflammato rie s c o mpare d with plac e bo All NS AIDs are as s o c iate d with a do uble d ris k o f s ympto matic he art failure in patie nts witho ut a his to ry o f c ardiac dis e as e
    48. 48. NSAIDS Cardiovascular Adverse Effects In patients w such a history, use of NSAIDs w associated w ith as ith m than 10-fold increase in heart failure ore If this link is found to be causal NSAIDs are estim ated to be responsible for up to 20% of hospital adm issions for congestive heart failure
    49. 49. NSAIDS Renal Adverse Effects  Changes in renal haem odynam (blood ics flow ordinarily m ), ediated by Prostaglandins Prostaglandins norm ally cause vasodilation of the afferent arterioles of the glomeruli This helps m aintain norm glom al erular perfusion and glom erular filtration rate (GFR), an indicator of renal function
    50. 50. NSAIDS Renal Adverse Effects In renal failure the kidney is trying to m aintain renal perfusion pressure by elevated Angiotensin II levels Angiotensin II also constricts the afferent ateriole into the glom erulus in addition to the efferent arteriole it norm ally constricts
    51. 51. NSAIDS are good, but m research is needed ore to im prove safety and increase efficacy
    52. 52. Discovery of COX-2 Selective inhibition of COX-2 results in anti-inflam atory m action w ithout disrupting gastroprotective prostaglandins. Daniel L. Sim ons m Brigham Young University
    53. 53. Discovery of COX-2 COX-1 is a constitutively expressed enzym e w a quot;house-keepingquot; role ith in regulating many norm physiological al processes COX-2 is an enzym expressed in e inflam ation m and it is inhibition of COX-2 that produces the desirable effects of NSAIDs.
    54. 54. Discovery of COX-2 OXICAM and COXIBS S Proved Efficacy and Safety FDA and EM approval under revision EA due to validation of Cardiovascular Adverse Effects
    55. 55. MYOCHRYSINE 1936 CORTONE M 1949 HYDROCORTONE 1952 DECADRON 1958 INDOCID 1965 (Indometacina) 1978 CLINORIL (Sulindac) DOLOBID 1982 (Diflunisal) VIOXX (Rofecoxib) 1998 SD: pain research tradition ARCOXIA 2002 (Eto ric o xib )
    56. 56. ARCOXIA Etoricoxib S O 2 CH3 Cl N N CH3
    57. 57. Etoricoxib world clinical program Accute Pain Chronic Pain – Post dental surgery pain – Osteoarthritis – Postoperative pain – Chronic LowBack Pain – Gout arthritis accute pain – Rheum athoid Arthritis
    58. 58. Etoricoxib world clinical program Phas e I / Pharmac o lo g y: 651 subjects Phas e II / Clinic al: OA, RA : 4888 patients. EDGE: GI tolerance: 2 studies >30.000 OA: 3953 patients, 90 mg RA: 2032 patients, 90 mg. MEDAL: CV safety OA: 8940 patients (6769:60m 2171: 90m g; g) RA: 2846 patients, 90 mg.
    59. 59. Po s tOp Pain Re s ults Max Pain Relief Score 3.5 Cambio promedio con ± EE 3.0 ETORICOXIB 120 mg 2.5 2.0 ETORICOXIB 60 mg 1.5 Ibuprofen 400 mg 1.0 Placebo 0.5 0.0 0 1 2 3 4 5 6 7 8 12 24 Time (hr) Initial Analgesic Effect with Etoricoxib 120 mg= 24 min Initial Analgesic Effect with Ibuprofen 400 mg.= 32 min Clin Therapeutics 2004;26:667-672.
    60. 60. PostOp Pain Results Average Pain Relief Score 3.5 Puntuación promedio de AD ± 3.0 2.5 ETORICOXIB 120 mg Naproxen 2.0 550 mg 1.5 Paracetamol 600mg /codeín 1.0 60 mg EE 0.5 Placebo 0.0 0 1 2 3 4 5 6 7 8 10 12 20 24 Time (Hours) Post-dose
    61. 61. Po s tOp Pain Re s ults Ortho pe dic S urg e ry • TKR & THR • Post Arthroscopy pain • Accute Phase: • Sym to Naproxen 1 gm ilar . • 2 - 7° day: • Better analgesic effect •Low need for other analgesics er 120 mg/day Anesth Analg 2005;101:1104-11. Act Anaesthesiol Scand 2007;51:316-321.
    62. 62. PostOp Pain Results 3.5 3.0 2.5 Puntuación ±EE ETORICOXIB120 2.0 mg (n=100) 1.5 Oxicodone/paracetamol 10/650< mg (n=100) 1.0 Placebo (n=25) 0.5 0.0 0 2 4 6 8 10 12 14 16 18 20 22 24 Time (Hours) Post-dose
    63. 63. PostOp Pain Results W “ as Rescue” edication needed ? m 100 % Patients that required rescue medication 90 72.0 80 70 Porcentaje ±SE 60 50 41.0** 40 30 22.0* 20 10 0 Etoricoxib 120 mg Oxicodone/Paracetamol Placebo (n=100) 10/650 mg (n=25) (n=100) *p<0.010 para Etoricoxib vs. oxicodona/paracetamol; p<0.001para Etoricoxib vs. placebo **p<0.010 para oxicodona/paracetamol vs. placebo
    64. 64. Tolerance Profile Vs. Oxicodone Adverse effects results Oxicodone/ Eto ric o xib paracetam ol 120 mg 10/650 mg Placebo (%) patients (n=100) (n=100) (n=25) Any AE 32 (32.0)** 71 (71.0) 6 (24.0) AE related to treatment 9 (9.0)** 64 (64.0) 2 (8.0) Com on AE m Dizziness 2 (2.0) 38 (38.0) 1 (4.0) Nausea 4 (4.0)** 33 (33.0) 0 (0.0) Vom it 0 (0.0)** 20 (20.0) 0 (0.0) Drow siness 0 (0.0) 19 (19.0) 1 (4.0) Post Op Alveolitis 15 (15.0) 15 (15.0) 2 (8.0) Headache 3 (3.0) 6 (6.0) 0 (0.0)
    65. 65. Etoricoxib Farmacokinetics Concentration M 1h ax. Biodisponibility 100% D o s tic s ne Not affected by Ki Stable after 7 days Dose r e nea food intake Li Effects Lasts 24 hs (72%) Concentration Effect Starts at 24 M inutes (50%)
    66. 66. Eto ric o xib Me tabo lis m Lowinteraction potential Elimination: M etabolized by several P450 system - 70% renal enzym es: - 20% feces CYP3A4 (∼60%) y CYP2D6, - <2% unaltered CYP2C9, CYP1A2 y CYP2C19
    67. 67. Medication Interaction MEDICATION EFFECT Ketoconazol, ASA, No effect Anti-H2, prednisona. ↓ 65% plasma concentration of ↑ Do s e Rifampicin Etoricoxib. Warfarin 120 mg of Etoricoxib ↑ 13% INR. INR Diuretics, IECAs y Al NSAIDS may ↓ anti-HBP effects ARA II Mo nito r BP No interaction with 60 y 90 mg. 120 mg Mo nito r Metotrexate increases MTX levels 28% MTX Birth control pills Increase de ethinil estradiol (50- 60%). -HRT Mic ro do s is
    68. 68. S afe ty Pro file Adverse effects 7.0 5.9 6.0 5.4 5.0 4.6 4.0 3.6 3.5 % 3.0 2.0 1.0 0.0 Cefalea Infeccón TRS Diarrea HTA Náusea
    69. 69. S afe ty Pro file Adverse Effects 8.5 9 7.5 8 6.5 7 5.8 6 4.8 4.8 5 4.1 4.3 3.4 4 3 2.1 2.1 % 2 1.2 1.1 0.9 1.2 0.1 0.4 0.4 1 0 ARXOXIA 90 ARCOXIA 60 ARCOXIA 120 NAPROXENO IBUPROFENO Placebo 2400 mg 1g Retired due to AE EA TGI. EA HTA
    70. 70. GI Adve rs e Effe c ts Patients with gastric ulcers or erosions diagnosed with endoscopy 100 100 90 90 80 80 72.0 70 70 60 60 58.7 50 50 Incidencia (%) Incidencia (%) 40 40 30 23.2* 22.7* 30 19.7* 17.4* 20 20 10 10 0 0 Placebo Etoricoxib Naproxeno Placebo Etoricoxib Ibuprofeno (n=229) 120 mg 1000 mg (n=221) 120 mg 2400 mg (n=236) (n=235) (n=216) (n=218) AR - OA 12 weeks treatment OA *p<0.001 para placebo y etoricoxib vs. naproxeno
    71. 71. Endo s c o py s tudie s c o mparing Eto ric o xib in OA & RA Incidence of GI Ulcers ≥3 mm - 12 weeks 35 25 30 25.27 20 17.02 Incidencia Acumulada, Incidencia Acumulada, 25 porcentaje (± IC 95%) porcentaje (± IC 95%) 20 1 5 15 1 8.12*** 10 0 7.42* 5 5 1.35* 1.86** 0 0 Placebo Etoricoxib Naproxeno Placebo Etoricoxib Ibuprofeno (n=247) 120 mg 1000 mg (n=233) 120 mg 2400 mg (n=251) (n=244) (n=221) (n=226) OA o AR OA *p<0.001 vs. naproxeno; **p<0.001 vs. ibuprofeno; ***p=0.007 vs. ibuprofeno Datos en Archivo, MSD.
    72. 72. Cardio vas c ular adve rs e e ffe c ts Pbo 60 mg 90 mg Naproxen N=1011 N=658 N=889 N=790 Incidence (%) HBP related AE 2.0 4.7 4.5* 3.5 HBP 1.5 4.0 3.3 2.8 Treatment 0.0 0.3 0.3 0.4 suspended due to HBP (%) Pbo 60 mg 90 mg Naproxeno N=1011 N=658 N=889 N=790 Incidence (%) Edema related AE 2.1 4.0 2.9 2.9 Lower Limb 1.9 3.2 1.3 2.3 Edema Treatment 0.3 0.3 0.2 0.1 suspended due to Lower Limb Edema (%) Note: * p<0.05 vs. Pbo
    73. 73. Us e with c autio n … Hiperlipidem heavy sm ia, okers Pregnancy: 6-9 month Severe renal Insufficiency Alergies Dehidration Moderate liver insufficicency
    74. 74. Co ntraindic atio ns – Specific Hypersensitivity or Allergy – Gastric Ulcer, GI Bleeding or acido-peptic disease history – Congestive Heart Insufficiency or ventricular disfunction – Uncontrolled HBP – Coronary syndrom –coronary surgeries es – Severe liver disfunction – Pregnancy – Children
    75. 75. Etoricoxib In ac c ute pain 120 m once a day g
    76. 76. Etoricoxib In Rhe umatho id Arthritis 90 m once a day g
    77. 77. Etoricoxib in Os te o arthro s is 60 m once a day g
    78. 78. Etoricoxib In c hro nic lo w bac k pain 60 m once a day g
    79. 79. Co nc lus io n I us e Eto ric o xib be c aus e … – Pow erful, quick and long lasting analgesic – Strong Anti - inflam atory m – Safe m edication – W supported by basic and clinical research ell – Backed up by a w know researcher in the industry ell n – Better than any other product I can prescribe An e xc e lle nt s o lutio n fo r many o f my pro ble ms …
    80. 80. I’ used Etoricoxib ve on myself… .
    81. 81. “ the neww In orld there w be no pain… ” ill Apc 7,17;21,4
    82. 82. Thanks !
    83. 83. Thanks !
    84. 84. Thanks !
    85. 85. nfo ? .org ore Imedical M ay nw om l. c leal@fe al@gmai le chaz

    ×