W20 Pain conditions Flashcards
What is the definition of pain?
An unpleasant sensory and emotional
experience associated with actual or potential tissue damage.
What is:
An analgesic?
Anti-pyretic?
Anti-inflammation?
A medication to reduce pain
Lowers body temp (fever)
Anti inflammatory- reduces inflammation
What is:
An analgesic?
Anti-pyretic?
Anti-inflammation?
A medication to reduce pain
Lowers body temp (fever)
Anti inflammatory- reduces inflammation
Example of an
anti-inflammatory?
Analgesic?
Anti-pyretic
NSAID e.g. Aspirin/Ibuprofen
Paracetamol/Codeine/NSAID
Paracetamol, NSAID
What does paracetamol do?
What are the features?
Reduces the production of prostaglandins
(PG) in the brain and spinal cord
-Child= suspension – easier to swallow + taste
-Soluble tablets – easier to swallow & Soluble tablets – easier to swallow & absorbed more quickly absorbed more quickly
-Safe in pregnancy and breastfeeding
-Dose based on narrow age bands – not practical for consumers to calculate dose based on body-weight (mg/kg)
What are some brands/formulations of paracetamol (acetaminophen)
Medical
Disprol effervescent tablets
Panadol tablets
Hedex tablets
Alvedon suppositories
Paracetamol oral suspension (Calpol)
Paracetamol 500mg caplets:
Dosage?
Adults, the elderly and children over 16
years of age:
Take 1-2 caplets up to four times a day, as
required. Do not take more than 8 caplets in required.
Children 10 to 15 years:
Take 1 caplet up to four times a day, as
required. Do not give more than 4 caplets in 24 hours.
Do not give to children under 10 unless
otherwise advised by your doctor
Paracetamol Suspension
Suitable for children:
- From 2 months for post-immunisation pyrexia
- From 3 months for fever and pain
- Shake the bottle before use
e.g. 120mg/5ml (infant)
250mg/5ml (sixplus)
Uses of Paracetamol:
For mild to moderate pain e.g.
- Headache
- Migraine
- Toothache
- Dysmenorrhoea
- Fever
- Osteoarthritis
Uses of Paracetamol:
- For mild to moderate pain e.g.
- Headache
- Migraine
- Toothache
- Dysmenorrhoea
- Fever
- Osteoarthritis
- Less GI irritation compared with NSAIDs
Cautions of paracetamol?
- In people with liver or kidney dysfunction
- In those taking WARFARIN- Can increase the risk of bleeding if taken regularly
- Overdose- nausea and vomiting then liver failure (after 4-6 days)
Examples of Non-selective NSAIDS
- Ibuprofen
- Aspirin
- Naproxen
- Diclofenac
- Indomethacin
- Mefenamic acid
- COX-2 inhibitors e.g.
- Etoricoxib
- Celecoxib
NSAID Mechanism of action
Inhibit prostaglandin (PG) synthesis by
reversibly inhibiting cyclo-oxygenase
(COX) enzymes — COX-1 and COX-2
* COX-1 produces PG that help to maintain COX-1 produces PG that help to maintain gastric mucosal integrity and platelet-initiated
blood clotting
* COX-2 produces PG that mediate pain and
inflammation
Uses of NSAIDS:
For mild to moderate pain
Sprains, Strains
Headache
Dysmenorrhoea
Toothache
Colds and flu
Arthritis
NSAIDs
May not be suitable for people with:
- Asthma (can induce asthma attack in 10%)
Class effect - Kidney impairment (dec renal function)
-CVD and Hypertension - Prev stomach ulcers (inc bleeding risk)
- Inflammatory bowel disease e.g. Crohn’s disease or Ulcerative colitis
- Lupus
Contraindications of NSAIDs
- Hypersensitivity to NSAID
- Active peptic ulceration or gastro intestinal bleeding
- Severe heart, renal or liver failure
- Pregnancy- Non-selective NSAIDs
- Contraindicated after 30 weeks of pregnancy (Do not sell in pregnancy)
- Breastfeeding-Aspirin contraindicated
Interactions of NSAIDs
- Anticoagulants/antiplatelets
- Other NSAIDs
- Ciclosporin
- Diuretics
- ACE inhibitors
- Lithium
- Methotrexate
- SSRIs
NSAIDs-Ibuprofen
- Adult oral dose= 200mg-400mg up to 3 times a day (no more frequently than every 4 hours)
- Max dose= 1200mg in 24 hours
- Take with or after food
NSAIDs-Naproxen:
Used for?
Instructions- How to use?
-Licensed for period pain and menstrual
cramps for ≥15 – 55 years of age
- No more than THREE 250mg tablets per day
- Take with or just after a meal or snack
- Not to be taken for more than three days
in any one cycle
- Do not take with another NSAID
NSAIDs- Aspirin (acetylsalicylic acid)
- For mild to moderate pain in adults and children over 16
-Contraindicated in <16 years – can cause
Reye’s syndrome (resulting in serious liver
and brain damage)
-Usual adult oral dose = 300mg – 600mg every
4 to 6 hours. Max dose = 3600mg / 24 hours
-Disclaimer = Aspirin 75mg for cardiovascular
risk - not for pain - prolonged effect as an anti-
platelet
Aspirin uses?
Migraine
Headache
Toothache
Dysmenorrhoea
Cold and flu like symptoms
Fever
Can Codeine/Dihydrocodeine be purchased OTC?
- Adults + children over 12 years of age
-Can’t buy codeine as a single ingredient OTC - Combination product OTC e.g.
-Co-codamol 8mg/500mg = Paracetamol 500mg + Codeine 8mg
-Nurofen plus = Ibuprofen + Codeine
*Tolerance and dependence risk – OTC supply limited to 3 days
How does codeine work?
- Activates and binds to Mu opioid receptors in the brain and spinal cord (CNS)
*Metabolised by liver enzymes (CYP2D6) into morphine
*Genetic variability in metabolism
-Unpredictable effect
-Some will have little effect / big effect (fast metabolisers)
Uses of Codeine?
- Acute moderate pain (not anti-pyretic & not anti-inflammatory)
- Acute lower back pain
- When simple analgesics (e.g. Paracetamol, Ibuprofen or Aspirin), have not been effective or tolerated
Codeine cautions!
- Common side effects = constipation, nausea, drowsiness
- Although can be used in Pregnancy – would not sell OTC = refer to GP
- Contraindicated in breastfeeding
How does Dihydrocodeine work?
- Acts directly on Mu opioid receptors
- Not metabolised to active moiety
-More predictable effect? - Only in combination with paracetamol, OTC
- Similar indications/ cautions/Contraindications to codeine
Caffeine
A weak stimulant that is thought to enhance the analgesic effect & increase absorption(?)
Antihistamines
Can act as muscle relaxants and can help with sleep e.g. Diphenhydramine, doxylamine
Dysmenorrhoea
Primary (16-25)
- A few hours before/during menstruation
Secondary (30-45)
- Ofter starts after several years of painless periods
-Pain not consistently related to menstruationbut is exacerbated by it.
Sprain vs Strain
Symptoms?
Sprain = a torn, stretched or twisted ligament. Symptoms = bruising, swelling, inability to move the joint. e.g., sprained ankle or knee
Strain = The stretch or tearing of muscles or tendons. Symptoms = tenderness and swelling
Sprains and Strains
When to refer / Danger symptoms
Fracture or dislocation- inability to weight bear
Severe pain on movement
Persistent pain even when at rest
Numbness
Symptoms that have not improved after 48 hours
Treatment of sprains and strains
Protection
Rest
Ice
Compression
Elevation
= PRICE
Strains and Sprains: Treatment
- Cold products in the first 48 – 72 hours after injury
- Paracetamol or topical NSAID (1st line –CKS)
- Ibuprofen oral
- Rubefacient and heat not be applied until 72 hours after an injury
Back pain
- Most lower back pain is non-specific
- Most often seen in those aged 35 to 55 years
- Up to 60% of adults have lower back pain at some point in their lives
- Common cause of absence from work
Risk factors of Back pain
Non modifiable:
- Age
- Genetics
Modifiable:
- Fitness
- Weight
- Mental Health
- Job related activities
- Smoking
What is Sciatica?
Symptoms?
Irritation or compression of sciatic nerve, (runs from the back of the pelvis through the buttocks and down both legs)
Symptoms = tingling sensation, may be described as shooting or stabbing pain
5-10% of people with non-specific lower back pain also have sciatica
Management of Sciatica
- Most effective treatment is to keep moving
-Exercise - Group exercise programme (biomechanical, aerobic, mind-body, combination of these) - Analgesics unlikely to eradicate pain but may help to reduce pain to a level to enable the person to stay active
- Psychological support if high risk of poor outcome
Pharmacological Management of Lower back pain
1st line - Oral NSAIDs e.g. Ibuprofen or Naproxen
-Consider risk factors
-Use lowest effective dose for shortest duration
-Limited evidence of benefit for sciatica
Codeine + Paracetamol
-Only consider if NSAID contraindicated, not tolerated or ineffective (for acute back pain only)
-Paracetamol alone not recommended (evidence)
Back pain- Red flags
Possible fracture:
- Major trauma
- Minor trauma in elderly, or osteoporotic
Possible tumour, or infection
- Age <20 or >50 years old
- History of malignancy
- Fever, chills, weight loss
- Recent bacterial infection
- IV drug use
- Immunosuppression
- Pain worsening at night, or when supine
Osteoarthritis
- Affect knees, hips & small joints of the hand
- Loss of cartilage with joint remodelling
- Activity related pain
- Typically aged >45 years
- No early morning stiffness (or stiffness lasting no longer than 30 minutes)
- Functional impairment- movement limited
Osteoarthritis
Pharmacological management
Pharmacological management:
- Paracetamol or topical NSAID = first line
- Consider oral NSAID if simple analgesia ineffective (topical NSAID should then be discontinued)
- Consider weak opioid e.g. codeine when required if NSAID not tolerated or not effective
Encourage non-drug measures:
- e.g. weight management and exercise physio
Tension Headache
- All age groups & both sexes equally- may last days
- Muscles around the head and neck tighten, resulting in pain
- Bilateral symptoms: Dull aching pain- forehead, temples, back of neck. Described ‘like a band around the head’ or a heavy weight pressing down on top of the head’. Non-pulsating
- Symptoms worsen as day progresses
What are the causes of tension headache
May:
-Stress
-Anxiety
-Bad posture
-Tiredness
-Eye strain
What is a Sinus Headache?
- Caused by build up of pressure in the sinuses e.g. during or after a cold
- Unilateral initially
- People may present with
- Throbbing pain- worse during head movement
- Toothache
- Pain in jaw on eating
- Pain that is worse in the morning
- Increased mucus
- More pain when bending forward
- May last days
Medication Overuse Headache:
- Caused by overuse of pain medication
-As the effect of the pain medication wears off, the withdrawal triggers the next headache
-Treatment = to gradually reduce the pain medication
-Stop for minimum 1 month
-Headaches may take weeks to resolve - Headache on 15 or > days/ month in a person with a pre-existing headache disorder and
- Regular overuse for > 3 months of:
- For ergotamine, triptans, opioids and combination analgesics intake must be 10 days or more per month
- For NSAID & paracetamol, intake must be 15 days or more per month
- Headaches not due to other reasons
Describe a Migraine
-symptoms
-causes
- Severe headache that is often associated with other symptoms e.g. nausea, vomiting, visual disturbances, increased sensitivity to light (photophobia) or sound (phonophobia) and/or smells (osmophobia)
-May be related to serotonin levels in the brain
-With low levels, blood vessels contract
-Headaches occur when blood vessels dilate again
-Average attack last 24hours
Migraine with aura
Aura- A warning signal before a migraine begins:
- Visual disturbances e.g. zig zag patterns, flashing lights, blind spots
- Tingling sensations or stiffness in neck,
shoulders, limbs
- Co-ordination issues or problems with speaking
Migraine wihtout aura:
Symptoms can include-
- Nausea and vomiting
- Photophobia, phonophobia and/or osmophobia
Possible Migraine Triggers:
Changes in routine e.g. sleep
Hormonal changes e.g. menstrual cycle
Emotional changes e.g. stress, anxiety
Medicines e.g. oral contraceptives
Dietary Factors e.g. missed/irregular meals
Physical Factors e.g; poor posture, low glucose
Environmental Factors e.g. bright flickering lights or screens, noise, smoking
Migraine treatment options:
- Paracetamol, Aspirin or Ibuprofen
- Gut motility can slow down during a migraine attack- products may take longer to absorb
- Different formulations are available that can disperse in the stomach and are absorbed quicker
Migraine treatment:
- Co-codamol= Not recommended as codeine can make nausea and vomiting worse
- Migraleve pink= licensed for migraine- contains parcetamol and codeine with buclizine (an antihistamine that helps to prevent nauseous feeling)
Sumatriptan
- Triptan” - 5HT1 agonist - not an analgesic
Licensed (18 – 65yo) where clear diagnosis of migraine - One tablet ASAP after migraine onset
Dose can be repeated after symptoms recur after min 2 hours - Acts on vascular 5-HT1D receptor found predominantly in cranial blood vessels leading to vasoconstriction
Sumatriptan: Contraindications
- Allergy to sumatriptan
- Myocardial infarction
- Ischaemic heart disease
- Coronary vasospasm (Prinzmetal’s angina)
- Peripheral vascular disease
- Hypertemsion
- Stroke
- Liver impairment
When to refer Migraines to a GP?
- Sudden, severe, frequent or cluster headaches
- Migraine headaches for the first time
- Headaches in children
- People experiencing headaches:
- following a head injury
- with slurred speech
- with confusion
- with a rash, stiff neck or vomiting
Meningitis symptoms:
Fever, cold hands and feet
Refusing food and vomiiting
Drowsy, difficult to wake
Stiff neck, dislike bright lights
Convulsions, seizures
Severe headache
