Pain and pain killers (A Stepwise approach & Guide) with focus on NSAIDs (Ibuprofen)

1. Pain and Pain Killers
A stepwise approach & Guide
with focus on NSAIDs (Ibuprofen)
(Dr. Santosh R. Achwani)
ACCESS Clinic DIP 2

2. 1. Definition of Pain

3. What is Pain: International Association
for the Study of Pain (IASP)
(Unpleasant)
- C1: Sensory (Physical) or
- C2: Emotional experience
(Perceptional, psychological)
- C3: associated with actual/
potential tissue damage.
► Definition:
► Diagnosis: C1/C2 + C3
► Assessment: H/O: SIQOR – AAA – ODP
P/E: Pain Quantification, Origin
► Background Information: (2: Types of Pain - PP, 3: Classification,
4: Quantification, 5: WHO Pain Ladder)  6: Treatment

4. 2. Types of Pain
(Pathophysiology)

5. 1. Nociceptive Pain:
- Origin: Peripheral: Skin/Viscera: body organs**Damage
- Stimulus: carried by nerve fibers (sensitive to stimulus)
- Target: **Brain (Neural Pain pathways – not damaged)
- Less intense (0-6), mild to moderate category, a/c or c/c,
amicable with WHO level 1-2 painkillers*** (GP: OPD)
2. Neuropathic Pain:
- Origin: CNS/PNS (abnormal neural activity in CNS/PNS)**Damage
- Reason: damage (injury), dysfunction, disease
- Target: perceived as pain by Brain**Target
- More intense (7-10), severe to worst pain category, a/c or c/c,
needs WHO level 3 painkillers*** (Specialist Care)
Types of Pain perceived by Human body

6. No nerve damage Mixed Nerve Damage

7. 3. All Classifications of Pain

8. Classifications for categorization & diagnosis
► Classifications:
 Time duration: Acute Vs Chronic
 Anatomical location: body parts (Head, Leg, Arm, Back)
 Intensity: Mild, Moderate & Severe
 Origin (etiology): Somatic / Visceral - Nociceptive,
Neuropathic, Mixed

9. 4. Quantification of Pain

10. Quantification of Pain in GP: OPD
►Numerical pain scale
►0: No Pain
►1-3: mild pain, 4-6: moderate pain, 7-9: severe pain,
►10: worst pain
► Verbal pain scale
►No pain  mild  moderate  severe  very severe  worst pain
► Visual Analogue pain scale (VAS)
►No pain  worst pain
► Wong-Baker faces pain scale rating (facial grimace)

12. 5. WHO Pain Scale

13. ► 1. PCM
► 2. NSAIDS (Ibuprofen)
Additional:
► 1: Opioids
Additional:
(P/O, Inj, S/C, Patches)
► 1: CNS/PNS drugs

14. 6. Treatment options

15. Treatment Options for Pain
Pharmacological (According to WHO pain Ladder)
► Level 1:
 PCM +/- *NSAIDs (*Ibuprofen)
► Level 2:
 PCM + *NSAIDs +/- Weak Opioids (*Ibuprofen)
 PCM + *NSAIDs +/- Strong Opioids (*Ibuprofen)
► Level 3: (*Ibuprofen)
 PCM + *NSAIDs + Strong Opioids + Neuromodulators
(ADM: SSNRI/TCA, AEM) +/- Non Pharma Options**
**E.g.: Physical Therapy, Biofeedback, Relaxation therapy,
Cognitive/Behavioural Therapy, Accupuncture, TENS,
Interventional Approaches (Spinal Cord Stimulation) etc.

16. Mainstay of treatment regime
► Mainstay: PCM + NSAIDs (Ibuprofen)
► Advantages:
 Easily available (OTC)
 Quick (peak: Empty stomach = 45 mins, with food = 1-2
hrs, T1/2: 2 hrs)
 Effective (additive effect when used in combination)
 Safe: Children
 Long window of dose delivery
 Minimal interaction with other meds (Warfarin, Li, Mtx)
► Dosages (Mini-pill: 200 mg, Low d.: 400 mg, Adult d.: 600 mg)
► Regime: q 4-6 hourly, Max dose: 1-12 yrs: 1.2 gm/day, 12-17
yrs: 2.4 gm/d, >17 yrs: 3.2 gm/day

17. Mainstay of treatment regime
► Combinations:
 Ibuprofen + PCM
 Ibuprofen + Caffeine (A/c pain, Migraine Headaches)***
 Ibuprofen + Oxycodone/Hydrocodone (C/c pain)
► Indications:
 Myalgia (Muscle-ache/spam pain, Dysmenorrhea)
 Fever (mild - moderate), Arthralgia (Joint pain, body pain)
 Arthritis (Rheumatic: RA, PA, AS; Non arthritic: OA)
 Neuropathic pain (Sciatica, LBP w Radiculopathy, TN)
 A/c pain, C/c pain, Cancer pain, Migraine
 Other: Fractures, toothache, headache, post – op pain

18. Mainstay of treatment regime
► Caution:
 Hepatic Impairment: Avoided
 CKD: Dose reduction (Dose Max: 1-12 yrs: 30 mg/kg/day,
12-17 yrs: 40 mg/kg/day, >17 yrs: 60 mg/kg/day)
 MC s/e: GI irritation, GI bleeding (co-prescribe: PPI)
 Beware: Nephrotoxicity (dose dependant)
 Best Usage:
►Diverse use profile
►Short term, lower dosages, more control
►Minimal period, maximum benefit
►Lookout for s/e in susceptible patients

19. Thank you