CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
Peripheral neuropathy is a common condition, encountered by physicians as well as neurologists. However, a large number of challenges remain. These include difficulty in diagnosing, delay in diagnosis, investigations and lack of effective treatments. This presentation discusses these unmet needs and provides suggestions to overcome them.
Zonisamide is among the newer broad spectrum anti-epileptic drugs, effective against focal and generalized epilepsies. It can be taken once daily and is well tolerated. The current article focuses on clinical efficacy and safety of zonisamide in epilepsy (as add on or as monotherapy). There is long term data as well as comparative studies against carbamazepine.
CHRONIC PAIN AND DEPRESSION: Cause or Effect or Linked?Sudhir Kumar
Chronic pain and depression are both common conditions, and in many patients, they co-exist. This presentation looks at the link between chronic pain and depression. Various drugs that can be used to treat chronic pain/depression have been discussed, with a special emphasis on tricyclic antidepressants.
Peripheral neuropathy is a common condition, encountered by physicians as well as neurologists. However, a large number of challenges remain. These include difficulty in diagnosing, delay in diagnosis, investigations and lack of effective treatments. This presentation discusses these unmet needs and provides suggestions to overcome them.
Zonisamide is among the newer broad spectrum anti-epileptic drugs, effective against focal and generalized epilepsies. It can be taken once daily and is well tolerated. The current article focuses on clinical efficacy and safety of zonisamide in epilepsy (as add on or as monotherapy). There is long term data as well as comparative studies against carbamazepine.
Fibromyalgia is characterized by chronic widespread pain, increased tenderness at specific sites known as “tender points,” unrefreshing sleep, fatigue and cognitive dysfunction not attributable to other disease states.
Fibromyalgia affects 2–4% of the general population and of those affected, 80–90% are female. In general, symptom onset occurs between the ages of 30 and 60.
While the etiology of fibromyalgia is not entirely clear, associations with trauma, adverse life events, impaired mood (e.g., depression), anxiety, irritable bowel syndrome, irritable bladder syndrome, cold intolerance, paresthesias and other medical condition have been described. Consequently, a patient tailored approach to treatment is ideal to address both symptoms of fibromyalgia and any associated conditions.
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
Pain in the elderly. How to better understand and rate it.Ross Finesmith M.D.
It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.
Palmitoylethanolamide in the Treatment of Neuropathic Pain Sudhir Kumar
Neuropathic pain is quite common. It is associated with severe disability and adversely affects the quality of life of sufferers. Current treatment options for neuropathic are not very effective. Moreover, they are associated with significant adverse effects. A new naturally occurring substance- PALMITOYLETHANOLAMIDE (PEA)- has been found to be effective and safe in treating neuropathic pain. The current presentation looks at the efficacy of PEA in neuropathic pain.
Acute neuropathic pain - Stephan Schug - SSAI2017scanFOAM
A talk by Stephan Schug at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
An update on the epidemiology and treatment of neuropathic pain. The slides were developed for a presentation in a departmental seminar at the Curtin University, Australia.
Fibromyalgia is characterized by chronic widespread pain, increased tenderness at specific sites known as “tender points,” unrefreshing sleep, fatigue and cognitive dysfunction not attributable to other disease states.
Fibromyalgia affects 2–4% of the general population and of those affected, 80–90% are female. In general, symptom onset occurs between the ages of 30 and 60.
While the etiology of fibromyalgia is not entirely clear, associations with trauma, adverse life events, impaired mood (e.g., depression), anxiety, irritable bowel syndrome, irritable bladder syndrome, cold intolerance, paresthesias and other medical condition have been described. Consequently, a patient tailored approach to treatment is ideal to address both symptoms of fibromyalgia and any associated conditions.
Conclusions:
74% of patients discharge home with moderate to severe pain --> with or without treatment before
ED patients should receive proper pain management, avoiding delays such as those related to diagnostic testing or consultation
In order to further improve patient care we must now apply our knowledge regarding acute and chronic pain treatment base on pharmacology of the drugs
Ongoing research in the area of ED patient pain management conducted and an algorythm or clinical guidelines in this area should be developed
Effective physician and patient educational strategies should be developed regarding pain management, including the use of pain therapy adjuncts and how to minimize pain after disposition from the ED
Pain in the elderly. How to better understand and rate it.Ross Finesmith M.D.
It is often difficult to determine the amount of pain an elderly person is experiencing.This is complicated by dementia and verbal impairment. This presentation describes helpful methods to assess pain in the elderly.
Palmitoylethanolamide in the Treatment of Neuropathic Pain Sudhir Kumar
Neuropathic pain is quite common. It is associated with severe disability and adversely affects the quality of life of sufferers. Current treatment options for neuropathic are not very effective. Moreover, they are associated with significant adverse effects. A new naturally occurring substance- PALMITOYLETHANOLAMIDE (PEA)- has been found to be effective and safe in treating neuropathic pain. The current presentation looks at the efficacy of PEA in neuropathic pain.
Acute neuropathic pain - Stephan Schug - SSAI2017scanFOAM
A talk by Stephan Schug at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
An update on the epidemiology and treatment of neuropathic pain. The slides were developed for a presentation in a departmental seminar at the Curtin University, Australia.
Current opiate prescription treatment has led to increased deaths, patients with marginal improvement in pain with minimal improvement in quality of life and high system utilization.
The integrated high-risk patient pain management clinics have been established to increase quality of pain care, stabilize high-risk patients and reduce impact of on primary care physicians and clinic utilization. These clinics are one aspect of a comprehensive plan to increase high quality pain care and reduce opiate deaths.
Mental Health – In this current period of data collection rates of
depression in all groups were reduced number of patients with mild MDD < 10%, number of patients with moderate < 7%, number of patients with severe depression < 7% and # of patients with all levels of MDD by 23%. The change in sample depression was significant with p =.01. 37% of patients had a score that indicates a likely full diagnosis of PTSD.
LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
PET CT beginners Guide covers some of the underrepresented topics in PET CTMiadAlsulami
This lecture briefly covers some of the underrepresented topics in Molecular imaging with cases , such as:
- Primary pleural tumors and pleural metastases.
- Distinguishing between MPM and Talc Pleurodesis.
- Urological tumors.
- The role of FDG PET in NET.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdf
Neuropathic pain management in the elderly
1. Muneer Nagi1, Adam Fox1, Melissa Selinger1, Matt Penano1
1PharmD Candidates - Nova Southeastern University College of Pharmacy
CONCLUSION
Considerations in the selection of pharmacological treatment of neuropathic pain in
the elderly include:
Drug efficacy for the types of neuropathic pain
Increased frequency of polypharmacy
Side effect profile and tolerability specific to this population.
Effective management of pre-existing comorbidities and risk reduction of developing
additional comorbidities before initiation or during pharmacological treatment
Gabapentin and pregabalin: minimal side effects, favorable for polypharmacy
implications
Tricyclic antidepressants: effective but SE problematic in elderly
Topical lidocaine 5%: effective for some types of pain with negligible side effects
SNRIs: effective and relatively well tolerated
Opioids: long term safety unknown, but useful in combination therapy
Tramadol: decreased seizure threshold, renal and hepatic dosing
Carbamazepine, Lamotrigine: efficacy data inconsistent; used for trigeminal neuralgia
Topical capsaicin: long-term safety unknown in high concentration patch
Combination therapy: limited clinical data and must be individualized, but often seen
in practice
PHARMACIST ROLES
• In the elderly:
Knowledge of NP
Effectively assist to manage comorbidities
Prevent drug-disease interactions
Educate patient/caregiver
Monitor adherence, compliance, medication effectiveness, etc.
Effectively manage polypharmacy
LIMITATIONS
This paper did not consider in-depth details of superiority/noninferiority of medications,
cost analyses, and QOL implications. There are a limited amount of head-to-head
comparative studies, therefore they were not included. The samples included in the meta-
analyses did not consider nor analyze patients with pre-existing conditions and/or
polypharmacy.
REFERENCES1.Vinik A. The approach to the management of the patient with neuropathic pain. The Journal of clinical endocrinology and metabolism. Nov 2010;95(11):4802-4811.
2. Ahmad M, Goucke C. Management Strategies for the Treatment of Neuropathic Pain in the Elderly. Drugs Aging. 2002/12/01 2002;19(12):929-945.
3. Reisner L. Pharmacological Management of Persistent Pain in Older Persons. The Journal of Pain. 3// 2011;12(3, Supplement):S21-S29.
4. Schmader KEMD, Baron RDRMED, Haanpää MLMDPHD, et al. Treatment Considerations for Elderly and Frail Patients With Neuropathic Pain. Mayo Clinic Proceedings. Mar 2010 2010;85(3):S26-S32.
5. McCarberg BMD, Barkin RLP, Zaleon CP. The Management of Neuropathic Pain With a Focus Upon Older Adults. [Review]. American Journal of Therapeutics May 2012;19(3):211-227; 2012.
6. McCarberg B, Barkin RL, Zaleon C. The management of neuropathic pain with a focus upon older adults. American journal of therapeutics. May 2012;19(3):211-227.
7. O'Connor AB. Neuropathic pain: quality-of-life impact, costs and cost effectiveness of therapy. PharmacoEconomics. 2009;27(2):95-112.
8. Smith BH, Torrance N. Epidemiology of neuropathic pain and its impact on quality of life. Current pain and headache reports. Jun 2012;16(3):191-198.
9. Stacey BR. Management of Peripheral Neuropathic Pain. American Journal of Physical Medicine & Rehabilitation. 2005;84(3):S4-S16.
10. Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the Pharmacological Management of Neuropathic Pain: An Overview and Literature Update. Mayo Clinic Proceedings. 3// 2010;85(3, Supplement):S3-S14.
11. Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. The Lancet Neurology. Aug 2010. 2013-02-24 2010;9(8):807-819.
12. Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathic pain on health-related quality of life: review and implications. Neurology. Apr 10 2007;68(15):1178-1182.
13. Chen H, Lamer TJ, Rho RH, et al. Contemporary Management of Neuropathic Pain for the Primary Care Physician. Mayo Clinic proceedings. Mayo Clinic. 2004;79(12):1533-1545.
14. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in neuropathic pain: Diagnosis, mechanisms, and treatment recommendations. Archives of Neurology. 2003;60(11):1524-1534.
15. Haanpää M, Attal N, Backonja M, et al. NeuPSIG guidelines on neuropathic pain assessment. PAIN. 1// 2011;152(1):14-27.
16. Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: An evidence based proposal. Pain. 12/5/ 2005;118(3):289-305.
17. Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations. PAIN. 12/5/ 2007;132(3):237-251.
18. Finnerup NB, Sindrup SH, Jensen TS. The evidence for pharmacological treatment of neuropathic pain. PAIN. 9// 2010;150(3):573-581.
19. Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. Journal of Comorbidity. 2011;1(1):28–44.
20. Sinnige J, Braspenning J, Schellevis F, Stirbu-Wagner I, Westert G, Korevaar J. The Prevalence of Disease Clusters in Older Adults with Multiple Chronic Diseases - A Systematic Literature Review. PLoS One. Nov 2013. 2013-11-18 2013;8(11).
21. Patel KV, Guralnik JM, Dansie EJ, Turk DC. Prevalence and impact of pain among older adults in the United States: Findings from the 2011 National Health and Aging Trends Study. PAIN®. 12// 2013;154(12):2649-2657.
22. Fine PG. Chronic Pain Management in Older Adults: Special Considerations. Journal of Pain and Symptom Management. 8// 2009;38(2, Supplement):S4-S14.
23. Haanpää ML, Gourlay GK, Kent JL, et al. Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities. Mayo Clinic Proceedings. 3// 2010;85(3, Supplement):S15-S25.
24. Guay DRP. Adjunctive pharmacological management of persistent, nonmalignant pain in older individuals. Aging Health. Feb 2006 2012-06-29 2006;2(1):135-144.
25. Sultan A, Gaskell H, Derry S, Moore A. Duloxetine for painful diabetic neuropathy and fibromyalgia pain: systematic review of randomised trials. BMC Neurol. 2008/08/01 2008;8(1):1-9.
26. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, Gabapentin, or Their Combination for Neuropathic Pain. New England Journal of Medicine. 2005;352(13):1324-1334.
27. Gordon DB, Love G. Pharmacologic management of neuropathic pain. Pain Management Nursing. 12// 2004;5, Supplement(0):19-33.
28. McGeeney BE. Pharmacological Management of Neuropathic Pain in Older Adults: An Update on Peripherally and Centrally Acting Agents. Journal of Pain and Symptom Management. 8// 2009;38(2, Supplement):S15-S27.
29. O'Connor AB, Dworkin RH. Treatment of Neuropathic Pain: An Overview of Recent Guidelines. The American Journal of Medicine. 10// 2009;122(10, Supplement):S22-S32.
30. Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. General Hospital Psychiatry. 5// 2009;31(3):206-219.
31. Haslam C, Nurmikko T. Pharmacological treatment of neuropathic pain in older persons. Clinical interventions in aging. 2008;3(1):111-120.
32. Mou J, Paillard F, Turnbull B, Trudeau J, Stoker M, Katz NP. Efficacy of Qutenza® (capsaicin) 8% patch for neuropathic pain: A meta-analysis of the Qutenza Clinical Trials Database. PAIN. 9// 2013;154(9):1632-1639.
33. Vorobeychik Y, Gordin V, Mao J, Chen L. Combination Therapy for Neuropathic Pain. CNS Drugs. Dec 2011. 2012-01-12 2011;25(12):1023-1034.
BACKGROUND
• The elderly/geriatric population:
by 2030, will be about 70 million in the US4,5.
is anyone whom is 65 years or older2
has the highest prevalence of age-related comorbidities and chronic diseases,
including pains4
• Neuropathic pain (NP) :
is one of the most common types of chronic pains in the elderly3
arises from a lesion or a disease affecting the somatosensory system17
clinical manifestation is symptomatic experience of both parasthesias and
dysesthesia11
• Current pharmacological management include:
TCA’s, SNRIs, calcium channel alpha 2 delta ligands, topical lidocaine 5%,
mu agonists, antiepileptics, and topical capsaicin (all strengths)17,18
considerations for polypharmacy, multimorbidity, and age related changes in
pharmacokinetics4
• In 2002, insurance data showed that cost per patient with NP was $17 355 US vs.
$5 715 US without NP7
OBJECTIVES
Discuss current pharmacological management.
Identify adverse events associated with pharmacological treatment(s).
Present potential comorbid conditions.
METHODS
Literature
Search
• Databases used: Science Direct, Proquest Central, Nation Institute of Health PubMed Central
• Key Words: neuropathic pain, management, epidemiology, elder, combination therapy, multimorbidity
• Applied Boolean Search Operator using “AND” to narrow our results
Search
Period
• 2000 to present
Inclusion
Criteria
• Full text only, English language, peer-reviewed, scholarly articles, relevance to objectives
Exclusion
Criteria
• Animal studies, non–English text, and expert review/opinions.
Results
• 5 primary references selected; 27secondary references selected
Pharmacological Stepwise Management
First Line
TCAs
SNRIs
Calcium
channel α2-δ
ligands
Lidocaine
Second Line
Opiates
Tramadol
Third Line
Antiepileptic
Topical Capsaicin
Combination
therapy
RESULTS
References Study/Article types Objectives/Endpoints Comments
“Algorithm for Neuropathic Pain
Treatment: An evidenced based
proposal” by Finnerup et. al [2005]
Meta-analyses of
randomized double-blind
placebo-controlled RCTs
Up-to-date calculations of NNT and
NNH are used as the basis for
evidence-based treatment
algorithm.
Lowest NNTs are: TCA’s, then
opioids, gabapentin, and
pregabalin in peripheral
neuropathic pain
Limited data on central NP
“Pharmacologic management of
neuropathic pain: Evidence-based
recommendations” by Dworkin et. al
[2007]
Meta-analyses of RCTs and
systematic reviews
Review and
recommendations
EBM Clinical Guidelines
Review results of RCTs
Present evidenced-based
guidelines for pharmacological
management
Provide specific recommendations
based on statistically significant
efficacy data of the medications
and reduction of chronic NP.
Endorsed by the American Pain
Society
Only oral or topical
pharmacotherapy in adults are
presented in these guidelines
Did not consider combination
therapy due to lack of data during
that period.
“The evidence for pharmacological
treatment of neuropathic pain” by
Finnerup et al. [2010]
Updated meta-analyses of
double-blind placebo
controlled RCTs
Up-to-date calculations of NNT and
NNH values in neuropathic pain
Discussion of these measures for
treatment strategies
Carbamazepine no longer
considered as a treatment option
Combination therapy considered,
but discussion is limited due to
inadequate published studies
“Treatment Considerations for Elderly
and Frail Patients With Neuropathic
Pain” by Schmader et al. [2010]
Supplemental article
Primary and secondary
literature used
Review how aging and frailty affect
the treatment of older adults with
neuropathic pain
Discusses general considerations
for geriatric pharmacotherapy
“Combination Therapy for
Neuropathic Pain: A Review of
Current Evidence” by Vorobeychik et
al. [2011]
Review article
Primary and secondary
literature used ?????
Summary of relevant information
on this topic
Not intended to be an analytic
review
Summarizes published RCTs
relevant to combination therapy
for non-cancer related NP and
cancer-related NP
DISCUSSION
Treatment Comorbid Considerations Comorbidity Precautions Polypharmacy Considerations Side Effects in Elderly Contraindicated
Co-morbidities
FirstLineTreatment
Calcium channel α2-δ
ligands5,10,16-18
Gabapentin
Pregabalin
Insomnia
Fibromyalgia (pregabalin)
Restless leg syndrome (pregabalin)
Partial onset seizures
Anxiety (pregabalin)
Mood (gabapentin)
ESRD (pregabalin)
Hepatic insufficiency (gabapentin)
Hepatic/renal insufficiency
Fall or fracture risk
Uncontrolled HTN
CHF
Known altered mental status
No clinically significant drug
interactions
Antacids reduce absorption
(gabapentin)
Drugs that are known to depress the
CNS
Peripheral edema
Cognitive impairment
Gait impairment
Blurred vision
CHF class III/IV
SNRIs5,10,16-18
Duloxetine
Venlafaxine
Depression
Anxiety
Fibromyalgia (duloxetine)
Chronic arthritis pain (duloxetine)
Chronic lower back pain (duloxetine)
Hepatic/renal insufficiency
Seizure history
Uncontrolled HTN
(venlafaxine)
MAOIs
Serotonergics
NSAIDs
Warfarin
Blood pressure elevations
(minimal with duloxetine)
Hyponatremia
Constipation
Sedation
Arrhythmia
(venlafaxine)
Hepatic insufficiency
(duloxetine)
ESRD (duloxetine)
TCAs5,10,16-18
Secondary
Nortripyline
Desipramine
Tertriary
Amitrypyline
*use should be avoided
Insomnia
Depression
Overactive bladder
Alzheimer's patients treated
with ACh inhibitors
Known cognitive decline
Uncontrolled HTN
QTc prolonging drugs
MAOIs
Serotonergics
NSAIDs
Warfarin
Anticholinergic effects
Cognitive changes
Orthostasis (fall risk)
Hip fractures (nortriptyline)
Cardiotoxicity
Sedation
Weight gain
Blood pressure elevations
Hepatic failure
Heart block
Recent MI
Glaucoma
Prostatic hypertrophy
Urinary retention
Chronic constipation
Lidocaine 5% patches5,10,16-
18
Localized pain History of adverse cardiac
events
Class I antiarrhythmics
(Minimal systemic absorption [<5%])
Rash
Erythema
Broken skin
Severe hepatic
impairment
SecondLineTreatment
Opioids5,10,16-18
Morphine
Oxycodone
Methadone
Levorphanol
Tapentadol
Oxymorphone
Breakthrough pain
Acute or chronic pain of other etiologies
History of adverse cardiac events
(tapentadol)
Severe renal insufficiency (CrCL
>30mL/min) (tapentadol)
Renal insufficiency
(morphine)
Hepatic impairment
History of substance abuse
COPD
Cardiac insufficiency
Known cognitive decline
QTc prolonging drugs (methadone)
Drugs that are known to depress the
CNS
MAOI
Anticoagulants
Drowsiness
Dizziness
Constipation
Gastroparesis
Impaired cognition
Pruritis
Respiratory Depression
Decrease in motor function (fall
risk)
Cardiovascular collapse
Hyperalgesia
Ileus
Arrhythmia
Respiratory depression
Tramadol5,10,16-18 Breakthrough pain
Acute or chronic pain of other etiologies
Seizure history
Renal insufficiency
Hepatic impairment
Serotonergic
MAOIs
Antipsychotics
CYP450 2D6 inhibitors
CYP450 3A4 inhibitors
Medications that are known to
decrease seizure threshold
Drowsiness
Dizziness
Constipation
Seizure risk
Orthostatic hypotension
ThirdLineTreatment
Anticonvulsants5,10,16-18
Carbamazepine
Lamotrigine
Epilepsy Renal insufficiency
Hepatic insufficiency
Strong CYP inducers/inhibitors Anticholinergic effects
Drowsiness
Dizziness
Cognitive impairment
Blurred vision
Coordination difficulties
AV block
Topical capsaicin5,10,16-18,32
OTC and 8% (Rx)
Localized pain No known drug interactions Erythema/local skin irritation Broken skin
Combination Therapy29, 33 Varies Varies Varies Varies Varies