Fw: [ChronicPainConnection] NSAIDS

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NSAIDS-line pharmacologic intervention for most cervical conditions. NSAIDs reduce pain at low doses and decrease inflammation at high doses. Patients require a therapeutic NSAID plasma level to achieve anti-inflammatory effect. NSAIDs with once-a-day dosing improve compliance and increase probability of achieving therapeutic levels. Controlling inflammation is paramount when treating cervical radiculopathy. Aspirin rarely is recommended because it binds irreversibly to cyclo-oxygenase and incites gastritis, requiring large doses to reach anti-inflammatory effect. Traditional NSAIDs provoke multiorgan toxicity, including peptic ulcer disease, renal insufficiency, and hepatic dysfunction. The recently released cyclo-oxygenase isomer type 2 (COX-2) NSAID inhibitors confer the same analgesic/anti-inflammatory benefits without multiorgan toxicity. All NSAIDs have a dose-related ceiling point for analgesia above which higher doses fail to provide additional pain relief. The same precautions should be observed with COX-2 NSAIDs, despite their reduced risk of organ toxicity. Use muscle relaxants to potentiate the NSAID analgesic effect and not necessarily to control muscle spasm. Muscle relaxants primarily sedate by relaxing muscle with subsequent relaxation of the patient. Oral corticosteroids treat inflammatory cervical radiculopathy. No documented case of avascular necrosis exists in the literature when the total prednisone dose or corticosteroid equivalent stayed under 550 mg. Some providers use a methylprednisolone dose pack (tapers from 24 to 0 mg over 7 days); however, concern exists regarding adequate dosing to treat radiculopathy. A prednisone dose schedule outlined below stays within the 550-mg limiting amount. Tricyclic antidepressants (TCAs) decrease pain and reduce nonrestorative sleep. Side effects include dry mouth, constipation, and weight gain. Selective serotonin reuptake inhibitors (SSRIs), despite lacking side effects associated with TCAs, are inferior to TCAs in treating diabetic peripheral neuropathic pain, and their efficacy in relieving neck and back pain compared to other antidepressants remains unknown. Additional medications include membrane-stabilizing agents (eg, gabapentin, carbamazepine). Gabapentin has demonstrated efficacy in treating diabetic peripheral neuropathic pain. Other analgesics (acetaminophen, tramadol) provide pain relief without inflammation control. Opioids may be prescribed orally, transdermally, rectally, or sublingually on a scheduled basis. Patients on opioids should sign a medication contract restricting them to a single physician and pharmacy, scheduled medication use, no unscheduled refills, and no sharing or selling medication. Patients prescribed opioids long term with a previous history of alcoholism or other addiction are at risk for dependence. Therefore, consider recommending cotreatment of these patients with a psychologist or other addiction specialist. Lastly, many short-acting opioid preparations contain acetaminophen, which may be toxic in doses above 3 g/d. Consequently, patients should be counseled to avoid toxicity by avoiding other pharmaceuticals containing acetaminophen.Drug Category: Corticosteroids -- Used to treat inflammatory cervical radiculopathy. Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.Prednisone (Deltasone) -- Decreases inflammation by inhibiting polymorphonuclear leukocyte and fibroblast migration, stabilizing lysosomes, and decreasing capillary permeability.Methylprednisolone dose pack (Solu-Medrol, Medrol, Depo-Medrol) -- Decreases inflammation by inhibiting polymorphonuclear leukocyte and fibroblast migration, stabilizing lysosomes, and decreasing capillary permeability.Drug Category: Anticonvulsants -- Use of certain anti-epileptic drugs, such as the GABA analogue Neurontin (gabapentin), has proven helpful in some cases of neuropathic pain. Have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, altered perception of pain, and increase in pain threshold.Gabapentin (Neurontin) -- Has anticonvulsant properties and antineuralgic effects; however, exact mechanism of action is unknown. Structurally related to GABA but does not interact with GABA receptorsCarbamazepine (Tegretol) -- May reduce polysynaptic responses and block posttetanic potentiation. Inhibits nerve impulses by decreasing influx of sodium ions into cell membrane.Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin) -- DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.Tramadol levels decrease with carbamazepine; coadministration with opiates, hypnotics, sedatives, and alcohol increases CNS depressionCyclooxygenase-2 (COX-2) inhibitors -- COX-2 inhibitors include valdecoxib (Bextra) and celecoxib (Celebrex). Indications for specific types of pain vary for each, but may include of pain associated with osteoarthritis, rheumatoid arthritis, menstrual pain, or general pain. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.Celecoxib (Celebrex) -- Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased.precautions Category D after 34 wk of pregnancy; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab resultsRofecoxib (Vioxx) -- On September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of rofecoxib (Vioxx) from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo. Alert: On September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of rofecoxib (Vioxx) from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo. A major FDA study of rofecoxib found an apparent 3-fold increase in the risk of sudden cardiac death or heart attack among patients who had taken higher doses of the drug compared to the risk of patients who had not recently received similar medication. The report showed that even patients taking the standard starting dose of 12.5 mg or 25 mg of rofecoxib had a 50% greater chance of heart attack or sudden cardiac death than patients on any dose of celecoxib (Celebrex). The large-scale study was conducted after analyzing the medical records of 1.4 million people insured by Kaiser Permanente in Oakland, Calif, between 1999-2001. Note: The study has inherent limitations in that it is observational, rather than randomized and controlled.Valdecoxib (Bextra) -- Second generation COX-2 inhibitor that offers a very rapid onset and prolonged efficacy. Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, valdecoxib does not inhibit COX-1 isoenzyme, decreasing GI toxicity.Deterrence/Prevention: a.. Cervical myofascial pain can be prevented if overuse is avoided. Recommend appropriate ergonomic considerations for jobs that require repetitive use of the arm or shoulders. Any activity that requires sustained muscle contraction without rest puts the patient at risk. Appropriate posture also makes a significant difference in reduction of cervical myofascial pain. Since stress may play a role, relaxation techniques in conjunction with other stress relievers are integral to any treatment program for the patient prone to development of cervical myofascial pain. Advise the patient to avoid nutritional deficiencies, including deficiency of vitamins B-1, B-6, B-12, folic acid, vitamin C, and the elements calcium, iron, and potassium, as lack of these nutrients may contribute to trigger point pain.Complications: a.. Chronic pain and disability a.. Migraine and/or muscle contraction headaches a.. TMJ syndromePrognosis: a.. When the patient with cervical myofascial pain undergoes appropriate treatment(s) (eg, physical therapy, massage therapy, stretch and spray, trigger point injections), the prognosis is good.Patient Education: a.. Patients with cervical myofascial pain need to be educated on the factors or underlying problems that may contribute to their pain and loss of mobility. The physical therapist can educate the patient on proper exercise habits and instruct them in a home exercise program for stretching and reconditioning. The patient also may benefit from specific exercises and strategies to improve posture awareness and body mechanics with activities of daily living. If poor workplace ergonomics contribute to the patient's condition, offer instruction in proper ways to modify and revamp the workstation. Cervical myofascial pain is a treatable condition, as long as the patient is educated on the condition and takes an active role in the recovery process.Medical/Legal Pitfalls: a.. Remember that cervical myofascial pain can be present at the same time as other more serious medical conditions. The term myofascial pain tends to imply that the patient does not have a serious illness. If the patient's symptoms are resistant to traditional treatment for cervical myofascial pain, further workup is indicated. If a history of trauma exists, order cervical flexion/extension films to rule out the possibility of instability. MRI also may be helpful to rule out any significant abnormality within the structure of the cervical vertebrae or spinal canal. The cervical discs also may be evaluated. If the pain is in the shoulders or chest wall, be aware that visceral pain may refer to these areas and even produce some myofascial findings on examination. Be open-minded to the possibility that another problem also may be present. a.. Maintaining proper cervical posture and cervicothoracic strength and flexibility, avoiding cervical trauma and repetitive cervical stress, and adhering to a healthy lifestyle which advocates proper nutrition, physical activity, and smoking cessation, might help prevent cervical disc disease.Complications: a.. Complications of cervical spine disorders may include the following: a.. Intractable axial or radicular pain a.. Myelopathy with associated weakness, hyperreflexia, and neurogenic bowel/bladder dysfunction a.. Radiculopathy with associated upper extremity weakness and numbnessPatient Education: a.. Educate patients to avoid aggravating factors (eg, vibrational stress from driving, cervical flexion, Valsalva maneuvers) that may exacerbate discogenic pain. a.. Additionally, instruct patients on correct posture and a home exercise program (eg, cervicothoracic stabilization, aerobic conditioning). a.. The clinician may fail to diagnose neck pain as a manifestation of serious systemic illness (eg, malignancy, infection). Consequently, neck pain evaluation demands a careful history with review of systems, physical examination, and judicious use of imaging to avoid this medicolegal pitfall. a.. Additionally, the clinician may fail to diagnose serious sequelae of cervical spine disorders (eg, myelopathy with resulting quadriparesis, radiculopathy with profound upper limb neurologic deficit) in a timely manner. Thus, neck pain evaluation requires a thorough neurologic history and physical examination. a.. Interventional cervical spine procedures (eg, epidural injections, discography) carry potential for complications, including epidural hematoma with subsequent spinal cord compression, infection, respiratory arrest, vertebral artery injury, and intrinsic spinal cord damage. Competency in such procedures, proper patient monitoring, and preparatory skills in managing such complications are mandatory.http://www.emedicine.com/PMR/topic25.htm