Non opiates
celecoxib
consider renal function
GI side effects
diclofenac, ibuprofen, naproxen, tenoxicam, ketoprofen
COX-1 vs. COX-2:
COX-1 is a "constitutive" enzyme, meaning it's always present and plays important protective roles in the stomach and kidney.
COX-2 is an "inducible" enzyme, meaning its levels increase during inflammation to promote pain and inflammation
Gabapentinoids: pregabalin, gabapentin
Antidepressants: nortriptyline, amitriptyline, venlafaxine
Skeletal muscle relaxants: baclofen, diazepam, orphenadrine (Norflex) Gastrointestinal antispasmodic: hyoscine butylbromide (Buscopan) Benzodiazepines/anxiolytics: lorazepam, diazepam
Sleeping tablets: zopiclone
Steroids: dexamethasone, prednisone
If depressed: citalopram, mirtazapine
Opiates
Miu, kappra, delta receptor
tramadol - weak opoid use to treat chronic pain - miu receptor ( 50mg tramadol - 10 mg of morphine ), used in caution for renal and hepatic impairment
codein - avoid in elderly, renal impairment, hepatic impairment
15mg codein = 4mg morphine
hydroxycodone x 2 of morphine
opiate causes CNS depression
morphine is gold standard for moderate to severe pain
use oxycodone when eGFR < 30 ( double the strength of morphine )
fentanyl is X 10 of morphine - use as s/c or IV - when renal / hepatic impairment ( egFR < 10)
methadone
Morphine
immediate release
sevredol -5-10mg Q4H
morphine liquid 2.5 - 5mg Q2H
Slow release
m-eslon 10mg BD
consider adding laxatives + antiemetic like domperidone PRN