NOTES ON PAIN MANAGEMENT

Dr. Saleh Mohammad Shoaib, Fakirhat UHC, Bagerhat

Paracetamol & NSAIDs (COX Inhibitors)

Appropriate doses of Paracetamol may be just as effective an analgesic and antipyretic as NSAIDs but without the risk of GI
bleeding or ulceration.

Paracetamol can be given at a dosage of 500–1000 mg orally every 6 hours, not to exceed 4 g/day maximum for short-term use.
Total paracetamol doses should not exceed 3 g/day for long-term use or 2 g/day for older patients and for those with liver
disease. Hepatotoxicity is of particular concern.

NSAIDs are antipyretic, analgesic, and anti-inflammatory. Treatment with NSAIDs increases the risk of GI bleeding 1.5 times; the
risks of bleeding and nephrotoxicity are both increased in elders. GI bleeding and ulceration may be prevented with the
concurrent use of PPI (eg, omeprazole, 20–40 mg PO OD) or with use of etoricoxib. Etoricoxib and the NSAIDs can lead to fluid
retention, kidney injury, and exacerbations of heart failure and should be used with caution in patients with that condition.

Topical formulations of NSAIDs (such as diclofenac 1.3% patch or 1% gel), placed over the painful body part for treatment of
MSK pain, are associated with less systemic absorption and fewer side effects than oral administration and are likely
underutilized in patients at risk for GI bleeding.

Name Usual Dose for Adults ≥ 50 kg Cost Comment

Paracetamol 500–1000 mg PO QDS (Max. daily 500 mg tab/0.8 tk • Not an NSAID because it has analgesic
(Napa, Ace, dose: Acute pain – 4 g, Chronic pain 665 mg XR (extend) and antipyretic effects but lacks peripheral
Reset) – 3 g, Older patiets and liver disease tab/1.5 tk anti-inflammatory effects.
– 2 g) Rapid caplet: 500 • Safe in all stages of pregnancy and
Usual Dose for Adults < 50 kg: 10– mg/0.8 tk lactation
15 mg/kg every 4 hours PO; 15–20 Rectal suppository: • Avoid concurrent hepatotoxic drugs
mg/kg every 4 hours PR, up to 2–3 60 mg/3.5 tk • Useful (+opioids) in CKD where NSAIDs
g/day 125 mg/4 tk are usually contraindicated
250 mg/5 tk
500 mg/8 tk
Paracetamol + 1-2 tablets every 4 hours or as 500 + 65 mg tab/2.5 • Activation symptoms
Caffeine (Napa needed. Max. 8 tabs/24 hours tk
extra, Ace plus)
Aceclofenac 100 mg BD 100 mg tab /4 tk • Has marked anti-inflammatory and
(Flexi, Reservix) 200 mg SR OD 200 mg SR tab/7 tk analgesic properties
Diclofenac 50–75 mg PO 2-3 times daily 50 mg tab/1.5 tk • Enteric-coated product; slow onset
Sodium Timed/Sustained release: 100–200 100 mg SR tab/4 tk • May impose higher risk of hepatotoxicity
(Clofenac) mg PO OD
Rectal suppository: 75-150 mg daily 12.5 mg sup./9 tk • Faster action than oral formulation
in divided doses 25 mg sup./12 tk
50 mg sup./15 tk
Diclofenac free Dispersible tablet: 2-4 tablets/day in 46.5 mg DT/4 tk • Disperses immediately (within 15 s),
acid (Clofenac divided doses quickly absorbed and acts rapidly (20-30
DT) min)
• Less GI irritation than diclofenac sodium
Diclofenac gel 1% gel 2–4 g 4 times daily 1% gel 50 gm/97 tk • Fewer side effects than oral formulations
(Clofenac,
Voligel)
Diclofenac Inj. Deep IM (gluteal): 75 mg 1-2 times 75 mg amp./15 tk • Contains 20 mg lidocaine in each
(Clofenac plus) daily (max. 2 days) ampoule
Diclofenac + Apply 1-inch band of gel to the 50 gm tube/100 tk • Menthol dilates blood vessels, gives
Menthol gel affected site 3-4 times daily with cooling effect and relieves pain
(Volinac gel) rubbing till the film disappears • Contains also Methyl Salicylate (anti-
inflammatory) and Linseed Oil
Ketorolac 10 mg PO every 4–6 hours (max. 40 10 mg tab/12 tk • Short-term use (< 5 days) only;
(Rolac, Torax, mg/day PO) otherwise, increased risk of GI side effects.
Etorac) IM/IV: 60 mg IM or 30 mg IV initially, 10 mg amp./32 tk • High efficacy, alternative to opioid
then 30 mg QDS IM or IV 30 mg amp./55 tk • Faster onset than other NSAIDs
60 mg amp./95 tk • Lower doses for elderly
• Short-term use (< 5 days) only
Mefenamic acid 250 mg PO QDS or 500 md TDS 250 mg/2.8 tk
(Dysmen) 500 mg/5 tk
Meloxicam 7.5 mg PO BD 15 mg tab/4 tk • Intermediate COX-2/COX-1 ratio similar
(Melcam) to diclofenac
Ibuprofen 400–800 mg PO QDS (For adults < 50 200 mg/0.88 tk • Relatively well tolerated and
(Inflam) kg: 10 mg/kg PO TDS/QDS) 400 mg/1.43 tk inexpensive.
Indomethacin 25–50 mg PO 2-4 times daily (max. 25 mg cap/1 tk • Higher incidence of dose-related toxic
(Reumacap) 200 mg/d) effects, especially GI and bone marrow
Sustained release: 75 mg BD 75 mg SR cap/4 tk effects.
Suppository: 1-2 per day 100 mg sup./9 tk
Nabumetone 500–1000 mg PO OD (max. dose 500 mg tab/15 tk • May be less ulcerogenic than ibuprofen,
(Nabumet) 2000 mg/day) 750 mg tab/22 tk but overall side effects may not be less.
Naproxen 250–500 mg orally every 6–8 hrs (For 250 mg/4 tk • Generally well tolerated. Lower doses
(Napro-A, adults < 50 kg: 5 mg/kg every 8 hrs) 500 mg/7 tk for elderly.
Ticoflex) • Not recommended under 5 y old at all.
Sustained release: 500 mg OD 500 mg SR tab/8 tk • Not recommended for 5 - 16 y old except
(Ticoflex SR)
JIA.
(Ticoflex gel) Gel: 2-6 times a day locally 10% 15 gm/60 tk
• Cardiovascular profile better than other
(Ticoflex 5 mg/kg BD 125 mg/5 ml: 50 NSAIDs
suspension) ml/35 tk
Naproxen + 375/20 mg or 500/20 mg BD (to be 375/20 mg tab: 8 tk • Don’t split, chew, crush or dissolve the
Esomeprazole taken at least 30 min before meal) 500/20 mg tab: 10 tk tablet
(Neso, Progesic)
Sulindac 150–200 mg PO BD 100 mg tab/5 tk • May cause higher rate of GI bleeding
(Lindac) 200 mg tab/9.5 tk • May have less nephrotoxic potential
Tolfenamic acid 200 mg PO at onset of migraine, 200 mg/10 tk
(Tufnil) another 200 mg PO 1-2 h later if
inadequate response
Etoricoxib 60 – 120 mg OD 60 mg tab/7 tk In contrast to conventional NSAIDs -
(Etorix) 90 mg tab/12 tk • Less GI irritation
120 mg tab/14 tk • Cardiovascular side effects more
Tramadol Start 25 mg PO OD. Slowly up-titrate 50 mg cap/8 tk • Adverse effects: nausea and dizziness,
(Anadol) to max. 100 mg PO QDS. (Max. daily 100 mg SR cap/12 tk but these symptoms typically abate after
dose: healthy adults = 400 mg, > 75 several days of therapy
y old = 300 mg, If CrCl <30 = 200 mg, • Remember possibility of serotonin
Cirrhosis = 100 mg) syndrome (high dose + SSRI/SNRI/TCA)
(Anadol Rectally: 50-100 mg not more often 100 mg sup./15 tk
suppository) than 4 hrly, max. 400 mg/d
(Anadol IM/slow IV (over 2-3 min): 50 – 100 Inj. 100 mg amp./20
Injection) mg every 4-6 hrs (max. 600 mg daily) tk
Paracetamol + 1-2 tablets QDS (max. 8 tabs/day) 325 + 37.5 mg tab/8 • Useful when NSAIDs are avoided (PUD,
Tramadol tk CKD, fluid retention etc.)
(Napadol,
Acetram)
Nalbuphine 10-20 mg IV/IM and adjusted as 10 mg amp./60 tk • Onset of action: IV = 2-3 min, IM = <15
(Nalbun) required 20 mg amp./100 tk min
• Side effects (uncommon): sedation,
sweating, nausea, vomiting, dizziness,
vertigo, dry mouth, respiratory depression,
headache
OD = once daily, BD = twice daily, TDS = three times daily, QDS = 4 times daily, PO = per oral, PR = per rectum, sup. = suppository,
mg/d = mg/day, amp. = ampoule, CrCl = Creatinine clearance, 75 y = 75 years, 1 h = 1 hour

ANALGESIA IN CKD
 Pain is under-recognized and undertreated in patients with kidney disease. The fact that it is more difficult to treat is no
excuse for inadequate management.

 Opiate analgesia is very effective but must be used with caution. Accumulation → significant side effects: constipation,
drowsiness, confusion, respiratory depression, twitching and seizures.

 If uncertain, seek expert pain advice.

 Use the World Health Organization (WHO) analgesic ladder.

STEP 1

 Paracetamol***: safe and effective in CKD. Requires no dose adjustment.

 NSAIDs:

• Usually contraindicated (pre-dialysis → deterioration in GFR; dialysis →↓ residual renal function).

• Can be an effective short-term measure, esp. musculoskeletal pain.

• Co-prescribe a PPI, as gastritis common.

STEP 2
 Tramadol***: 90% renally excreted, so ↓ dose and  interval (start 50mg 12h). (In CrCl < 30, max. dose = 200 mg/d)

 Avoid codeine and dihydrocodeine if eGFR <15mL/min. Hepatic metabolites accumulate in CKD. If used, reduce dose by 50%.

STEP 3
 Drug choice will depend on acuteness and severity of pain, desirable route of administration, and local availability. SC can be
used for rapid relief, with subsequent conversion to oral or transdermal.

 Morphine or diamorphine:

• Avoid, if possible, as breakdown products accumulate.

• If used short-term — morphine: initially 2.5mg SC 4 – 12h prn (?).

 Diamorphine: initially 1.25mg SC 4 – 12h prn.

 Buprenorphine:

• Effective. Nausea a prominent side effect.

• 200 – 400 micrograms sublingual or transdermal patches.

 Alfentanil:

• First-line SC opioid in renal failure.

• SC 250 micrograms 2–4h.

• Can be given as a continuous infusion.

• Use fentanyl for breakthrough, as alfentanil has short half-life.

 Fentanyl:

• <10% renally excreted.

• SC 25 micrograms 3 – 6h. Lozenges for breakthrough pain.

Transdermal patch very effective once pain controlled by other means.

 Hydromorphone: initially 1.3 mg orally 6 – 8-hourly + 1.3 mg prn for more severe pain.

 Oxycodone: start with OxyNorm ® (initially 2.5mg 8 – 12 h) for rapid pain control, and convert to OxyContin ® for less frequent
administration.

 Methadone: hepatic metabolites excreted in faeces. However, large interpatient pharmacokinetic variability means it should
probably be reserved for use by physicians familiar with its eccentricities.

[So, as a medicine practitioner, you have three weapons, paracetamol, tramadol and local analgesics.]

ANALGESIA IN CLD
Local Advice: rest, immobilization, ice/cold pack application, Crep bandage

Drugs: Paracetamol: max. 2 g/d

Tramadol (max. 100 mg/d)

Local analgesic – as needed

Avoid systemic NSAID.

NOTES ON MUSCLE RELAXANTS

Anti-spasmodics: Relieve spasms from peripheral musculoskeletal conditions

Spasmolytics: Relieve spasticity from UMN lesions (spinal cord injury, cerebral palsy, stroke, multiple sclerosis etc.)

Spasmolytics (Indicated for spasticity due to UMN type lesions)

Starting Max.
Name Cost Comment
dose dose
Baclofen 5-10 mg 20 mg 5 mg/5 tk • Adverse effects (High-dose): Excessive somnolence, respiratory
(Cap. Beklo) TDS QDS 10 mg/9 tk depression and coma.
25 mg/20 tk • Patients can become tolerant to the sedative effect with chronic
administration.
• Increased seizure activity has been reported in epileptic patients.
• Withdrawal from baclofen must be done very slowly.
 • Rare hepatotoxicity
Diazepam 2 mg BD 10 mg 5 mg tab/0.7 tk • Adverse effects: Addiction, withdrawal, ataxia, weakness, cognitive
(Tab/Inj. QDS 10 mg amp/3 tk impairment, memory dysfunction, poor coordination, fatigue and
Sedil) CNS depression.
Tizanidine 2 mg TDS 12 mg 2 mg/5 tk • Adverse effects: Drowsiness, hypotension, dizziness, dry mouth,
(Tab. TDS asthenia, and hepatotoxicity.
Relentus) • Drowsiness can be managed by taking the drug at night.
• Dosage must be adjusted in patients with hepatic or renal
impairment.
Dantrolene 25 mg 100 mg 25 mg/10 tk • Adverse effects: Weakness, hepatotoxicity, occasional sedation,
(Cap. OD QDS 50 mg/15 tk malaise, fatigue, diarrhoea
Relaxo) • Not indicated in muscle spasm resulting from rheumatic disorders.
Antispasmodics: drugs used to treat acute local muscle spasm (caused by local tissue trauma or muscle strains)
Cyclobenzaprine 20–40 mg/d in 5 mg/2 tk • Indications: Acute spasm due to muscle injury, inflammation
(Tab. Flexor) divided doses 10 mg/3 tk • Ineffective in treating muscle spasm due to cerebral palsy or spinal
(max. 60 mg/d) cord injury.
• Side effects: Antimuscarinic side effects, significant sedation,
confusion, transient visual hallucinations.
Carisoprodol 250 mg QDS 250 mg/6 tk • Has sedative, anxiolytic and anticonvulsant effects
(Tab. Carilax) • Side effects: Drowsiness, dizziness, headache

DRUGS FOR NEUROPATHIC PAIN

Lesions of the peripheral or central nociceptive pathways typically result in a loss or impairment of pain sensation. Paradoxically,
damage to or dysfunction of these pathways can also produce pain. For example, damage to peripheral nerves, as occurs in
diabetic peripheral neuropathy, or to primary afferents, as in herpes zoster infection, can result in pain that is referred to the
body region innervated by the damaged nerves.

Pain may also be produced by damage to the CNS, e.g: in some patients following trauma or vascular injury to the spinal cord,
brainstem, or thalamic areas that contain central nociceptive pathways. Such pains are termed neuropathic pain.

They are often severe and are typically resistant to standard treatments for pain. Successful management of neuropathic pain
often requires the use of more than one effective medication. Neuropathic pain is described as “burning,” “shooting,” “pins and
needles,” or “electricity”. Pain may be associated with numbness.

Oral Drug Starting Dose Typical Dose Cost Comment

st
1 line
Pregabalin 50 mg TDS 50-150 mg TDS 25 mg/10 tk • No significant drug interaction.
(Cap. (max 600 50 mg/14 tk • Adjust dose in kidney dysfunction
Pregaba) mg/day) 75 mg/18 tk • Both preferred over TCA in h/o HF/ arrhythmia/suicide
100 mg/22 tk risk
150 mg/32 tk • Relatively safe in accidental overdose
Gabapentin 100–300 mg 300–1200 mg 300 mg/16 tk • Gabapentin + Opioid = better analgesia
(Tab. Gaba) OD-TDS (300 TDS 600 mg/30 tk • Can be combined with duloxetine
mg/day every 5 • Side Effects: Pregabalin - Sedation, dizziness,
days) peripheral edema, weight gain Gabapentin – nausea,
somnolence, dizziness
Duloxetine 60 mg OD 60–120 mg 20 mg/7 tk • Shouldn’t be combined with other serotonin or NE
(Tab. (elders: 20 mg OD 30 mg/10 tk uptake inhibitors (i.e: SSRI, SSNRI, TCA)
Duloxen) BD) • Can be combined with pregabalin or gabapentin
Venlafaxine 37.5 mg BD 75 mg TDS 37.5 mg/6 tk • Side Effects: Duloxetine - Nausea (take after meals),
(higher dose 75 mg/11 tk Venlafaxine - HTN, ECG changes (Start with caution if CV
(Tab. Venlax)
may be risk)
needed)
2nd line
Nortriptyline 10 mg at night 10–150 10 mg/1 tk • TCAs may take several weeks for full analgesic effect
(Cap. Nortin) (10 mg every mg at 25 mg/1.5 tk • Slowly up-titrate to achieve the lowest effective dose
5 days) night • Side effects: Dry mouth, sedation, constipation, orthostatic
Amitriptyline 10 mg at night 10–150 10 mg/0.85 hypotension, cognitive dulling, blurred vision, urinary
(Tab. Tryptin) (10 mg every mg at tk retention, weight gain, seizure threshold lowering
5 days) night 25 mg/1.75 • Nortriptyline preferred over amitriptyline due to less
tk orthostatic hypotension and fewer anticholinergic effects
• Don’t use with SSRI/SSNRI (Serotonin syndrome!)
Tramadol 50 mg QDS 100 mg 2- 50 mg/8 tk • Side effects: Dizziness, vertigo, nausea, vomiting,
(Cap. 4 times 100 mg somnolence (symptoms lessen after several days)
Anadol/ daily SR/12 tk • Remember possibility of serotonin syndrome (high dose +
Anadol SR) Max. daily dose: healthy SSRI/SNRI/TCA)
adults = 400 mg, > 75 y old =
300 mg, If CrCl <30 = 200 mg,
Cirrhosis = 100 mg
OD = once daily, BD = twice daily, TDS = thrice daily, QDS = 4 times daily, GI = gastrointestinal, HF = heart failure, HTN =
hypertension, CV = cardiovascular, TCA = Tricyclic antidepressant, SSRI = selective serotonin reuptake inhibitor, NE =
norepinephrine, SSNRI = selective serotonin norepinephrine reuptake inhibitors, mg/d = mg/day

HOW TO PRESCRIBE ANALGESICS?

(Pt. is healthy adult, no h/o liver disease, CKD)

Acute pain (Road traffic accident, physical assault, trauma)

Severe pain: Apply ice/cold water pack locally 1. Inj. Rolac 60 mg IM stat 2. Tab. Rolac 10 1+1+1+1 – 5 days (A/M) later on
replaced by Reumacap SR 75 1+0+1 (A/M) if needed 3. Cap. Acifix 20 1+0+0 (B/M) with NSAID 4. Tab. Napa 500 2+2+2 – as
needed 5. Anadol suppository 100 mg P/R SOS 6. Tab. Pase 1 mg 0+0+1 – 7 days 7. Tab. Emistat 8 mg 1+1+1 – if nausea/vomiting
8. Volinac gel apply locally 4 times daily – as needed

Mild to moderate pain: Apply ice/cold water pack locally 1. Reumacap SR 75 1+0+1 (A/M) as needed 2. Cap. Acifix 20 1+0+0
(B/M) with NSAID 3. Tab. Napa 500 2+2+2 – as needed 4. Tab. Rivotril 0.5 mg 0+0+1 – as needed 5. Volinac gel apply locally 4
times daily – as needed

Chronic pain (e.g: Rheumatic conditions, osteoporosis)

Step 1: Oral paracetamol (3 g/d) + physiotherapy/Advice + topical analgesics

Step 2: Add one Oral NSAID to step 1, up-titrate to full dose

Step 3: Add Oral Tramadol to step 2, up-titrate to lowest effective or highest tolerable dose

Additional Steps: For chronic inflammatory conditions, add disease modifying agents

For Spastic conditions, add suitable muscle relaxant to appropriate step

For Neuropathic pain, add suitable agent

For pain related insomnia, add hypnotics

For osteoporosis, consider bisphosphonates

Steroid + Anesthetic injection into joint(s)/soft tissue when appropriate

Example 1 – Mechanical low back pain: A heavy manual worker (37 y old male, 73 kg) complains of mechanical back pain which
exacerbates on lifting heavy weights. He is otherwise healthy. No h/o liver disease/CKD.

Ideal prescription: Advice: / ১। ও ন ন। ২। ন ন । ৩। ন/ ন

/ ন। ৪। / ন ন। নও ন, নও ন, নও ন। ৫।
নগ ন ন (গ ন ন / ন গ ন / গ ন ন)।
৬। ও , গ , ন। ৭। / ন- ন। ৮। ন ন ন।
৯। ন/ ন ন( / ) ১০। , , ন ন ন । ১১। ন ন । ১২।
ন ন।

Drugs: 1. Tab. Napa 500 2+2+2 – cont. 2. Tab. Flexi 100 1+0+1 (A/M) – if pain 3. Cap. Progut 40 1+0+0 (B/M) – with Flexi 4.
Volinac gel apply locally 4 times daily – if needed 5. Tab. Sedil 5 0+0+1 – if sleep loss

Example 2 – Prolapsed lumber intervertebral disc with lumbago sciatica with muscle spasm : A 45 y old male diagnosed with
PLID with lumbago sciatica with spastic back muscles.

Ideal prescription: Advice: as example 1

Drugs: 1. Tab. Napa 500 2+2+2 – cont. 2. Tab. Flexi 100 1+0+1 (A/M) – if pain 3. Cap. Progut 40 1+0+0 (B/M) – with Flexi 4.
Volinac gel apply locally 4 times daily – if needed 5. Tab. Relentus 2 1+1+1 – 5 days, then 2+2+2 – 5 days, then 3+3+3 – as
needed 6. Cap. Pregaba 25 1+0+1 – 5 days, then 1+1+1 – 5 days, then Pregaba 50 1+0+1 – 5 days, then Pregaba 50 1+1+1 – as
needed 7. Cap. Anadol SR 100 1+0+0 (A/M) – 7 days, then 1+0+1 – as needed 8. Tab. Vergon 1+1+1 – if vomiting

[Note: Relentus, Pregaba, Anadol all may produce drowsiness/sedation. Short course of oral steroid/1 shot of IM steroid may be
tried]

Example 3 – Knee osteoarthritis: A diabetic, hypertensive 55 y old female diagnosed with Right knee osteoarthritis. She has
been taking various oral analgesics for about 2 years, but no significant improvement.

Ideal prescription: Advice: ১। ব্যথার জায়গায় গরম পানির স েঁক নিবব্ি (গ ন ন / ন

গ ন / গ ন ন)। ২। হােঁটু নব্শ্রাবম রাখবব্ি। ৩। ভানর কাজ করবব্ি িা। ৪। হােঁটু ব্ারব্ার ভােঁজ করবব্ি িা।
৫। ওজি কমাবব্ি। ৬। মানট, নপনি ব্া নিচু পায়খািায় ব্ বব্ি িা। ৭। হাই কবমাড/কবমাড সচয়াবর ব্ব পায়খািা/রান্নাব্ান্না করবব্ি। ৮। প্রবয়াজবি
হােঁটুর ব্যান্ড/নি কযাপ ব্যব্হার করবব্ি। ৯। প্রবয়াজবি ক্রাচ/঱ানি ব্যব্হার করবব্ি। ১০। আক্রান্ত হােঁটুবে যথা ম্ভব্ ভর কম নিবব্ি।

Inj. Trialon 40/Depomed 80 + 2 ml 1% lidocaine into Rt. knee joint after considering pros and cons with aseptic approach.

Drugs (if needed): 1. Tab. Napa 500 2+2+2 – cont. 2. Tab. Neso 500/20 1+0+1 (30 min B/M) 4. Volinac gel apply locally 4 times
daily – if needed

[Diabetes mellitus is likely to be uncontrolled for a few days following steroid injection. Keep management for that in mind.
Steroid injection can be given 3-monthly]

Example 4 – Axial spondyloarthritis: A 32 y male diagnosed with Axial SpA. He was well controlled on Cap. Reumacap SR 75 mg
BD for last 1 y but then developed PUD with occasional malaena. He doesn’t afford to have biologic therapy. Now he has severe
pain, for this he can’t take a job.

Ideal prescription: Counselling. Advice: ন। ন, ন, ন। ন।

Drugs: 1. Tab. Napa 500 2+2+2 – cont. 2. Tab. Etorix 120 1+0+0 (A/M) – cont. 3. Cap. Rabe 20 1+0+1 (B/M) – 3 months 4. Volinac
gel apply locally 4 times daily – if any benefit 5. Syp. Entacyd 4 tsf after meals and at night – 15 days 6. Tab. Gastalfet 1g 1+1+1+1
– 21 days 7. Cap. Anadol SR 100 1+0+0 (A/M) – 7 days, then 1+0+1 – 7 days, then 1+1+1 – as needed 8. Tab. Hemofix 1+0+1 – 3
months 9. Tab. Vergon 1+1+1 – if vomiting

[Q. Why etorix (etoricoxib) is given here? What is the problem with Reumacap (indomethacin)?]

Example 5 - Osteoporosis: A 62 y old lady complains of generalized bodyache for last 5 years. X-ray L/S spine shows osteopenia.

Ideal prescription: Advice: as example 1, Avoid falls, Let sunlight fall on bare skin

Drugs: 1. Tab. Napa 500 1+1+1+1 – cont. 2. Tab. Flexi 100 1+0+1 (A/M) – if pain 3. Cap. Progut 40 1+0+0 (B/M) – with Flexi 4.
Volinac gel apply locally 4 times daily – if needed 5. Tab. Sedil 5 0+0+1 – if sleep loss 6. Tab. Fossical-D 1+0+1 – 6 months 7. Tab.
D-rise 40,000 IU 1 cap weekly – 12 weeks 8. Tab. Bonemass – D (70+2800 mg) 1 tab weekly – take in early morning in empty
stomach in sitting posture with 2 glasses of plain water, avoid lying or eating for next 1 hour – 5 yrs

Try to avoid steroids

Example 6 – Rheumatoid arthritis: A 43 y old lady presented with multiple MCP, PIP, wrist and ankle arthritis. Provisionally you
think of Rheumatoid arthritis.

Ideal prescription: Counselling (i.e: about MTX therapy – duration, effect achieved months later, side effects, avoidance of
pregnancy etc), hot water bag over pain site
1 1
Drugs: 1. Tab. Cortan 10 mg (A/M) 3+0+0 – 2 wks, then 2 /2 +0+0 – 2 wks, then 2+0+0 – 2 wks, then 1 /2 +0+0 – 2 wks, then
1 1
1+0+0 – 2 wks, then /2 +0+0 – 2 wks 2. Tab. Methotrax 10 mg 1 /2 tab every friday – cont. 3. Tab. Folison 5 mg 1 tab every
saturday – cont. 4. Volinac gel apply locally 4 times daily – if needed 5. Tab. Bonemass – D (70+2800 mg) 1 tab weekly – take in
early morning in empty stomach in sitting posture with 2 glasses of plain water, avoid lying or eating for next 1 hour – 5 yrs 6.
Tab. Calbo 500 1+0+1 – 3 months

Intra-articular steroid if necessary

Example 7 – Peripheral SpA: A 25 y old male with inflammatory oligoarthritis. Family H/O Ankylosing spondylitis. HLA –B27
positive.

Ideal prescription: Counselling. Apply hot water bag locally. Advice: ন। ন, ন, ন।

ন।

Drugs: 1. Reumacap SR 75 1+0+1 (A/M) as needed 2. Cap. Acifix 20 1+0+0 (B/M) with NSAID 3. Tab. Napa 500 2+2+2 – as needed
4. Volinac gel apply locally 4 times daily – as needed 5. Tab. Salazine 500 mg (A/M) 0+0+1 – 7 days, then 1+0+1 – 7 days, then
1+1+1 – 7 days, then 2+1+1 – 7 days, then 2+1+2 – 7 days, then 2+2+2 – cont. (try to achieve lowest effective dose) 6. Tab.
Vergon 1+1+1 – if nausea/vomiting

Intra-articular steroid if necessary

Example 8 – Pain with CKD: A known case of CKD presented with traumatic ankle pain. He requires pain relief.

[Avoid NSAID]

Advice: Ankle rest, immobilization, ice/cold pack application, Crep bandage

Drugs: 1. Tab. Napa 500 2+2+2 – if needed (requires no dose adjustment in CKD) 2. Cap. Anadol 50 (A/M) 0+0+1 – 7 days, then
SR 100 (A/M) 1+0+0 – as needed (max. 200 mg/d if CrCl < 30) 3. Volinac gel – apply locally 4 times daily

Alternative: 1. Tab. Napadol 375/37.5 start with 1-2 tab daily (A/M), up-titrate to 6 tab/day on basis of GFR

Example 9 – Pain with CLD: A known case of CLD presented with traumatic foot pain. She requires pain relief.

[Avoid NSAID]

Advice: Foot rest, immobilization, ice/cold pack application, Crep bandage

Drugs: 1. Tab. Napa 500 1+1+1 – if needed (max. 2 g/d) 2. Cap. Anadol 50 (A/M) 0+0+1 – 7 days, then SR 100 (A/M) 1+0+0 – as
needed (max. 100 mg/d) 3. Volinac gel – apply locally 4 times daily

Alternative: 1. Tab. Napadol 375/37.5 start with 1-2 tab daily (A/M), up-titrate to max. 3 tab/day

Example 10 – Pregnancy: A 24 wks primigravida needs analgesia for traumatic hand pain.

[Avoid NSAID]

Advice: Hand rest, immobilization, ice/cold pack application

Drugs: 1. Tab. Napa 500 2+2+2 – if needed (max. 4 g/d) 3. Volinac gel – apply locally 4 times daily (short term)

Example 11 – Lactation: Same patient now breastfeeding her child. She needs analgesia for pain from dental caries.

Drugs: 1. Tab. Napa 500 2+2+2 – cont. 2. Tab. Flexi 100 1+0+1 (A/M) – if pain 3. Cap. Progut 40 1+0+0 (B/M) – with Flexi
 Choice of appropriate analgesic

Comment/Indication Appropriate analgesic

Avoidance/presence of NSAID side effects (GI, renal etc.) Paracetamol, Tramadol, Topical analgesic
Cost effective regimen wanted Paracetamol, Ibuprofen, Diclofenac, Aceclofenac,
Indomethacin
Avoidance/presence of PUD/Gastritis Paracetamol, Etoricoxib, Tramadol, Topical analgesic
Cardiovascular risk factor present (e.g: HTN, IHD) Paracetamol, Naproxen, Tramadol, Topical analgesic
Renal impairment present Paracetamol, Tramadol, Topical analgesic
Avoidance of future nephrotoxicity Paracetamol, Tramadol, Sulindac?, Topical analgesic
High efficacy needed Ketorolac (opioid alternative), Indomethacin, Aceclofenac,
Diclofenac, Tramadol, Nalbuphine
Quick action needed Parenteral: Ketorolac, Nalbuphine, Rectal: Diclofenac,
Indomethacin, Tramadol
Once daily dosing wanted Etoricoxib, Aceclofenac SR, Diclofenac SR, Naproxen SR,
Tramadol SR
Post surgical pain/short term severe pain relief Ketorolac, Nalbuphine, Tramadol, Diclofenac
Hepatic impairment present Low dose paracetamol (<2 g/d), low dose tramadol (<100
mg/d), Topical analgesic
Pregnancy Paracetamol, Topical analgesic (shortest term if NSAID)
Breastfeeding Paracetamol, NSAIDs, Topical analgesic

My personal favourite analgesics: Paracetamol, Aceclofenac, Indomethacin, Ketorolac, Tramadol

Antenatal and Postnatal Analgesia: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510

[In my 6 months in Fakirhat UHC, I have given steroid injections into following joints/soft tissues or indications: Knee OA,
Anserine bursitis, Plantar fascitis, Tibiotalar joint (ankle), Subtalar joint, PIP arthritis, De Quervain's tenosynovitis, flexor
tenosynovitis, MCP arthritis, elbow joint, lateral epicondylitis, glenohumeral joint, subacromial space, sternoclavicular joint,
greater trochanteric bursitis, temperomandibular joint. Results were excellent. Almost all patients experienced de-
intensification of pain (within 1-2 minutes) and near normalization of day to day activities related to that joint. 1 case of post-
injection flare of pain was managed with rest, ice and NSAID, and pain subsided within 2 days (which was expected). No h/o
iatrogenic septic arthritis. I use povisep soaked gauze to disinfect the site.

With steroid injection, it is possible to replace long-term frowns into medium-term smiles. So, why don’t you learn it?]