Adjuvant analgesics

2015 ◽  
Author(s):  
David Lussier ◽  
Russell K. Portenoy
Keyword(s):  
Neuropathic Pain ◽  
Clinical Experience ◽  
Bone Pain ◽  
Scientific Evidence ◽  
Opioid Therapy ◽  
Limited Data ◽  
First Line ◽  
Serious Illness ◽  
Dosing Strategies ◽  
Sequential Trials

In the management of pain associated with serious illness, ‘adjuvant analgesics’ usually are administered in concert with opioid therapy in an effort to improve outcomes when an opioid does not provide satisfactory relief with tolerable side effects. They may be divided into categories, including multipurpose drugs, and drugs used selectively for neuropathic pain, bone pain, pain due to bowel obstruction, or musculoskeletal pain. These drugs are selected for a trial based on limited data available and clinical experience; sequential trials may be undertaken when pain is refractory. Multipurpose drugs may be considered for any type of pain. The most useful include corticosteroids and analgesic antidepressants. For neuropathic pain, conventional first-line agents are gabapentinoids, analgesic antidepressants, and corticosteroids. Corticosteroids and bisphosphonates, are used commonly for bone pain. The indications and dosing strategies for these drugs are evolving as scientific evidence and clinical experience accumulate.

scholarly journals Patient profiles as an aim to optimize selection in the second line setting: the role of aflibercept

2021 ◽  
Author(s):  
B. González Astorga ◽  
F. Salvà Ballabrera ◽  
E. Aranda Aguilar ◽  
E. Élez Fernández ◽  
P. García-Alfonso ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Therapeutic Option ◽  
Scientific Evidence ◽  
Treatment Options ◽  
Line Treatment ◽  
Second Line ◽  
First Line ◽  
Effective Therapeutic Option ◽  
Line Setting ◽  
First Line Treatment

AbstractColorectal cancer is the second leading cause of cancer-related death worldwide. For metastatic colorectal cancer (mCRC) patients, it is recommended, as first-line treatment, chemotherapy (CT) based on doublet cytotoxic combinations of fluorouracil, leucovorin, and irinotecan (FOLFIRI) and fluorouracil, leucovorin, and oxaliplatin (FOLFOX). In addition to CT, biological (targeted agents) are indicated in the first-line treatment, unless contraindicated. In this context, most of mCRC patients are likely to progress and to change from first line to second line treatment when they develop resistance to first-line treatment options. It is in this second line setting where Aflibercept offers an alternative and effective therapeutic option, thought its specific mechanism of action for different patient’s profile: RAS mutant, RAS wild-type (wt), BRAF mutant, potentially resectable and elderly patients. In this paper, a panel of experienced oncologists specialized in the management of mCRC experts have reviewed and selected scientific evidence focused on Aflibercept as an alternative treatment.

scholarly journals Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

BMJ Open ◽  
2021 ◽  
Vol 11 (5) ◽  
pp. e045402
Author(s):  
Caroline King ◽  
Robert Arnold ◽  
Emily Dao ◽  
Jennifer Kapo ◽  
Jane Liebschutz ◽  
...  
Keyword(s):  
Palliative Care ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Misuse ◽  
Opioid Use ◽  
Serious Illness ◽  
Modified Delphi ◽  
Delphi Approach ◽  
Institutional Review ◽  
Management Guidance

IntroductionManagement of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.Methods and analysisWe chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants’ round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.Ethics and disseminationThis project received ethical approval from the University of Pittsburgh’s Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

scholarly journals Prevention of Hypotension following Spinal Anaesthesia in Caesarean Section - then and now

2012 ◽  
Vol 8 (4) ◽  
pp. 415-419
Author(s):  
J K Mitra
Keyword(s):  
Risk Factors ◽  
Clinical Practice ◽  
High Risk ◽  
Caesarean Section ◽  
Spinal Anaesthesia ◽  
Limited Data ◽  
First Line ◽  
High Risk Patients ◽  
Risk Patients ◽  
Poor Efficacy

Hypotension during spinal anaesthesia for caesarean section remains a common scenario in our clinical practice. Certain risk factors play a role in altering the incidence of hypotension. Aortocaval compression counteraction does not help to prevent hypotension. Intravenous crystalloid prehydration has poor efficacy; thus, the focus has changed toward co-hydration and use of colloids. Phenylephrine is established as a first- line vasopressor, although there are limited data from high-risk patients. Ephedrine crosses the placenta more than phenylephrine and cause possible alterations in the foetal physiology.http://dx.doi.org/10.3126/kumj.v8i4.6242 Kathmandu Univ Med J 2010;8(4):415-19   

Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document

2017 ◽  
Vol 21 (6) ◽  
pp. 513-524 ◽  
Author(s):  
Afsaneh Alavi ◽  
Charles Lynde ◽  
Raed Alhusayen ◽  
Marc Bourcier ◽  
Isabelle Delorme ◽  
...  
Keyword(s):  
Clinical Experience ◽  
Hidradenitis Suppurativa ◽  
Expert Panel ◽  
Scientific Evidence ◽  
Treatment Modalities ◽  
Modified Delphi ◽  
Consensus Document ◽  
Expert Opinions ◽  
Modified Delphi Technique ◽  
Necrosis Factor

Background: Hidradenitis suppurativa (HS) is a painful, debilitating, and poorly understood condition, which is suboptimally diagnosed, managed, and treated. Evidence supporting various treatment modalities is sparse. Objectives: To incorporate scientific evidence and expert opinions to develop useful guidance for the evaluation and management of patients with HS. Methods: An expert panel of Canadian dermatologists and surgeons developed statements and recommendations based on available evidence and clinical experience. The statements and recommendations were subjected to analysis and refinement by the panel, and voting was conducted using a modified Delphi technique with a prespecified cutoff agreement of 75%. Results: Ten specific statements and recommendations were accepted by the expert panel. These were grouped into 4 domains: diagnosis and assessment, treatment and management, comorbidities and a multidisciplinary approach, and education. Conclusions: These statements and recommendations will serve to increase awareness of HS and provide a framework for decisions involving diagnosis and management. Evidence suggests that antibacterial and anti–tumour necrosis factor therapies are effective in the treatment of HS. This is supported by the clinical experience of the authors. Further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS in Canada.

scholarly journals Comparative efficacy of pregabalin and baclofen in the rodent chronic constriction injury model of neuropathic pain

2018 ◽  
Vol 8 (1) ◽  
pp. 133
Author(s):  
Saurabh Kohli ◽  
Taruna Sharma ◽  
Juhi Kalra ◽  
Dilip C. Dhasmana
Keyword(s):  
Neuropathic Pain ◽  
Sciatic Nerve ◽  
Chronic Constriction Injury ◽  
Thermal Hyperalgesia ◽  
Mechanical Hyperalgesia ◽  
Comparative Efficacy ◽  
First Line ◽  
Injury Model ◽  
Different Types ◽  
Chronic Constriction Injury Model

Background: Neuropathic pain is associated with prolonged disability and is usually not responsive to conventional analgesics like NSAIDs and opioids. Even the recommended first-line drugs are effective in less than 50% patients. Thus, drugs with different mechanisms of action are needed. Baclofen, a GABA-B agonist has shown benefit in different types of neuropathic pains and is compared against pregabalin.Methods: The sciatic nerve was ligated in 2 groups of 6 rats each as per the chronic constriction injury model of neuropathic pain on day 0. After 14 days the effect of single doses of pregabalin (30mg/kg) and baclofen (5mg/kg) intraperitoneally were assessed over a 2 hours period. Thermal and mechanical hyperalgesia were assessed as measures of neuropathic pain by the hotplate and pin-prick method respectively.Results: Significant thermal and mechanical hyperalgesia was produced 14 days after sciatic nerve ligation in both the groups (p <0.05). Both pregabalin (p <0.001) and baclofen (p <0.01) were effective in decreasing thermal hyperalgesia throughout the two hours study period, but pregabalin was more effective as compared to baclofen (p <0.05) at 30, 60 and 120minutes. Both the drugs produced a significant decrease in mechanical hyperalgesia (p <0.01) throughout the study period. Again, pregabalin was the more effective drug (p <0.05) at all time points.Conclusions: Significant thermal and mechanical hyperalgesia was seen 14 days after sciatic nerve ligation. Both pregabalin and baclofen were effective in reversing the hyperalgesia, but pregabalin was the more effective of the two drugs at all time points.

Gabapentin Is a First Line Drug for the Treatment of Neuropathic Pain in Spinal Cord Injury

Spine ◽  
2004 ◽  
Vol 29 (7) ◽  
pp. 743-751 ◽  
Author(s):  
Funda Levendoğlu ◽  
Cemile Ö. Öğün ◽  
Önder Özerbil ◽  
Tunç C. Öğün ◽  
Hatice Uğurlu
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Neuropathic Pain ◽  
First Line ◽  
Cord Injury ◽  
Line Drug

What's in the Syringe?

2021 ◽  
Author(s):  
Juliet Jacobsen ◽  
Vicki Jackson ◽  
Joseph Greer ◽  
Jennifer Temel
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Clinical Experience ◽  
Clinical Skills ◽  
Psychological Skills ◽  
Illness Trajectory ◽  
Serious Illness ◽  
Case Based

What’s in the Syringe? Principles of Early Integrated Palliative Care, a guide for clinicians, teaches the psychological skills of outpatient palliative care. It does so based on a framework that articulates five challenges faced by patients through the illness trajectory. Each challenge forms the focus of a chapter. By helping patients meet each challenge, clinicians help them cope with serious illness. Patients thereby experience better quality of life and develop prognostic awareness. From this awareness, they can make informed medical and personal decisions. Each chapter focuses on clinical skills to support patients as they take up that challenge. Each chapter then ends with a discussion of how to collaborate with oncology colleagues around that challenge. Rich in illustrative examples and built around case-based chapters, the book draws on two decades of research and clinical experience.

scholarly journals Diabetic Peripheral Neuropathy: Epidemiology, Physiopathology, Diagnosis and Treatment

2019 ◽  
Vol 7 (1) ◽  
pp. 35-48
Author(s):  
Nazma Akter
Keyword(s):  
Neuropathic Pain ◽  
Peripheral Neuropathy ◽  
Diabetic Peripheral Neuropathy ◽  
Clinical Evidence ◽  
Current Treatment ◽  
Diabetic Patients ◽  
First Line ◽  
Diabetic Neuropathic Pain ◽  
Current Treatment Regimen ◽  
Limb Proprioception

Diabetic peripheral neuropathy (DPN) is a common complication of both type 1 and type 2 diabetes. It affects over 90% of the diabetic patients. It is widely accepted that the toxic effects of hyperglycemia play an important role in the development of this complication, but several other hypotheses have been postulated. It is typically characterized by significant deficits in tactile sensitivity, vibration sense, lower-limb proprioception, and kinesthesia. Painful DPN has been shown to be associated with significant reductions in overall quality of life, increased levels of anxiety and depression, sleep impairment, and greater gait variability. DPN is often misdiagnosed and inadequately treated. Clinical recognition of DPN is imperative for allowing timely symptom management to reduce the morbidity associated with this condition. The management of diabetic neuropathic pain consists basically in excluding other causes of painful peripheral neuropathy, improving glycemic control as a prophylactic therapy and using medications to alleviate pain. First line drugs for pain relief include anticonvulsants, such as pregabalin and gabapentin and antidepressants, especially those that act to inhibit the reuptake of serotonin and noradrenaline. In addition, there is experimental and clinical evidence that opioids can be helpful in pain control, mainly if associated with first line drugs. Other agents, including for topical application, such as capsaicin cream and lidocaine patches, have also been proposed to be useful as adjuvant in the control of diabetic neuropathic pain, but the clinical evidence is insufficient to support their use. The purpose of this review is to examine proposed mechanisms of DPN, summarize current treatment regimen. A better understanding of the mechanisms underlying diabetic neuropathic pain will contribute to the search of new therapies. Delta Med Col J. Jan 2019 7(1): 35-48

The use of cardiac imaging in the evaluation of athletes in the clinical practice: A survey by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and University of Siena, in collaboration with the European Association of Cardiovascular Imaging, the European Heart Rhythm Association and the ESC Working Group on Myocardial and Pericardial Diseases

2020 ◽  
pp. 204748732093201 ◽  
Author(s):  
Flavio D’Ascenzi ◽  
Francesca Anselmi ◽  
Sergio Mondillo ◽  
Gherardo Finocchiaro ◽  
Stefano Caselli ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
European Association ◽  
Screening Tool ◽  
Scientific Evidence ◽  
Heart Rhythm ◽  
First Line ◽  
Sports Cardiology ◽  
Preventive Cardiology ◽  
Pericardial Diseases

Aims Pre-participation evaluation (PPE) is recommended to prevent sudden cardiac death in athletes. Although imaging is not advocated as a first-line screening tool, there is a growing interest in the use of echocardiography in PPE of athletes. This survey aimed to map the use of imaging in the setting of PPE and explore physician beliefs and potential barriers that may influence individual practices. Methods An international survey of healthcare professionals was performed across ESC Member Countries. Percentages were reported based on the number of respondents per question. Results In total, 603 individuals from 97 countries participated in the survey. Two-thirds (65%) of respondents use echocardiography always or often as part of PPE of competitive athletes and this practice is not influenced by the professional or amateur status of the athlete. The majority (81%) of respondents who use echocardiography as a first-line screening tool perform the first echocardiogram during adolescence or at the first clinical evaluation, and 72% repeat it at least once in the athletes’ career, at 1–5 yearly intervals. In contrast, cardiac magnetic resonance is reserved as a second-line investigation of symptomatic athletes. The majority of the respondents did not report any barriers to echocardiography, while several barriers were identified for cardiac magnetic resonance. Conclusions Echocardiography is frequently used as a first-line screening tool of athletes. In the absence of scientific evidence, before such practice is recommended, large studies using echocardiography in the PPE setting are necessary.

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