Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Analgesics, Other
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Acetaminophen (Tylenol, Cetafen, Feverall, Aspirin Free Anacin)
Useful for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Nonsteroidal anti-inflammatory agents (NSAIDs)
Class Summary
These agents inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. NSAIDs may provide pain relief in the patient with TOS.
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
For relief of mild to moderately severe pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Ibuprofen (Motrin, Advil, Caldolor, Ibu, Provil)
NSAIDs used commonly for patients with mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Nabumetone
As with all the NSAIDs, this agent decreases the formation of prostaglandin precursors, has analgesic, antipyretic, and anti-inflammatory properties.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient’s response.
Opioid Analgesics
Class Summary
Moderate-to-severe pain in the setting of a flare or postsurgery may require an opioid analgesic.
Oxycodone (OxyContin, Oxaydo, Xtampza ER, Roxicodone)
Long-acting form of opioid currently used commonly for severe pain. Start with small dose and increase gradually.
Morphine sulfate (MS Contin, Arymo ER, Infumorph, Kadian)
Effective analgesic with good safety profile and ease of reversibility with naloxone. Various IV and PO doses used; commonly titrated until desired effect obtained.
Fentanyl transdermal (Abstral, Actiq, Duragesic, Fentora, Lazanda, Subsys)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. Excellent choice for pain management and sedation with short duration (30-60 min); easy to titrate. Easily and quickly reversed by naloxone. When using transdermal dosage form, most patients' pain controlled with 72-h dosing intervals; however, some patients may require dosing intervals of 48 h.
Antidepressants, TCAs
Class Summary
This complex group of drugs has central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. They increase synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by the presynaptic neuronal membrane.
Nortriptyline (Pamelor)
Has demonstrated effectiveness in treatment of chronic and neuropathic pain.
Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain.
Antidepressants, SSRIs and SNRIs
Class Summary
These agents may be considered as alternative to TCAs.
Fluoxetine (Prozac)
Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.
Sertraline (Zoloft)
Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.
Paroxetine (Paxil, Pexeva)
Antidepressant with potent specific 5-HT uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.
Duloxetine (Cymbalta)
Antidepressant with 5-HT uptake and norepinephrine uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.
Venlafaxine (Effexor XR)
Antidepressant with 5-HT uptake and norepinephrine uptake inhibition with fewer anticholinergic and cardiovascular adverse effects than TCAs.
Anticonvulsants, Other
Class Summary
Use of certain antiepileptic drugs, such as the GABA analogue gabapentin (Neurontin), has proven helpful in some patients with neuropathic pain.
Pregabalin (Lyrica) can be effective, tolerable, and easy to titrate compared to gabapentin.
Gabapentin (Neurontin, Neuraptine, Fanatrex FusePaq)
Has antineuralgic effects. Structurally related to GABA but does not interact with GABA receptors.
Pregabalin (Lyrica, Lyrica CR)
Structural derivative of GABA. Binds with high affinity to alpha2 -delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.
