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MANAJEMEN MANAJEMEN NYERINYERI

Pain ManagementPain Management

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NYERINYERI

Perasaan dan pengalaman emosional yg tidak menyenangkan

Akibat kerusakan jaringan (sudah terjadi atau berpotensi untuk terjadi)

International Association for the Study of Pain (1986)

Kombinasi kompleks dari elemen fisik (obyektif) &

elemen psikologis (subyektif)

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Klasifikasi Nyeri Sumber :

- Nyeri nosiseptif (stimulasi nosiseptor)- Nyeri neuropatik (kerusakan di jalur saraf itu

sendiri)

Durasi :- Nyeri kronik bukan karena keganasan- Nyeri kronik pada keganasan- Nyeri akut

Pain Mechanism – the basicPain Mechanism – the basic

Penghantaran nyeri di bagi menjadi 2 bagian besar:

- Perifer

neurotransmitter

utama adalah

prostaglanding

- Sentral

neurotransmitter

utama adalah

glutamat.

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Nyeri Nosiseptif vs Neuropatik

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Nyeri Kronik vs Akut

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Nyeri Kronik Dapat terbentuk dari nyeri akut yang tak teratasi dengan

optimal (central sensitization)

Nyeri yang berlangsung lebih dari 3 bulan, dan terus berlanjut walaupun tak ditemukan penyebabnya

Proses patologis kronik: - Kanker - Non Kanker

Umumnya merupakan nyeri neuropatik atau campuran nosiseptif dan neuropatik (mixed pain)

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Nyeri Kanker

Nyeri karena infiltrasi sel tumor

Nyeri karena terapi

Nyeri yang tak terkait dengan kanker atau terapinya

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SpinothalamicSpinothalamictracttract

PeripheralPeripheralnervenerve

Dorsal HornDorsal Horn

Dorsal root Dorsal root ganglionganglion

PainPain

ModulasiModulasi

TransduksiTransduksi

AscendingAscendinginputinput

DescendingDescendingmodulationmodulation

PeripheralPeripheralnociceptorsnociceptors

Kerusakan Kerusakan JaringanJaringan

PersepsiPersepsi

TransmisiTransmisi::- - PeriferPerifer

- - SentralSentral

CentralCentral PeriferPerifer

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How to RELIEVE the PAIN without

further damage ?

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PAINPAIN

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Anjuran WHO

Tahap I : Nyeri ringan ;

Asetaminofen atau NSAID/ COXIB dengan atau tanpa Adjuvant

Tahap II : Nyeri sedang-berat

opioid lemah (dgn/tanpa asetaminofen/NSAID) dengan atau tanpa adjuvant

Tahap III: Nyeri berat

opioid kuat dengan atau tanpa adjuvant

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Nyeri dan Inflamasi

Terapi :

- Antiinflamasi steroid (glukokortikoid) - Antiinflamasi nonsteroid (NSAID/AINS):

– Konvensional/ nonselektif– penghambat COX-2 (Coxib)

Mekanisme kerja NSAID/ COX2 ( Coxib ) Hambat sintesa PG

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Analgesik Non Opioid

Untuk nyeri ringan-sedang

Aspirin & NSAIDs:- beraksi di sistem saraf perifer (fase transduksi)- menghambat sintesis prostaglandin (mediator nyeri dan inflamasi) :

arthritis & nyeri post operasi

Paracetamol:- Inhibitor lemah sintesis Prostaglandin di perifer sifat anti inflamasi

hampir tidak ada. - Menghambat NO (neurotransmiter di medula spinalis) Lebih dominan

kerja di sistem saraf pusat daripada di perifer

16Downloaded from www.FDA.com

NSAID / COXIB

Celecoxib (Celebrex)

Rofecoxib (VIOXX)

Valdecoxib (BEXTRA)

Parecoxib (DYNASTAT)

Etoricoxib (ARCOXIA)

Nimesulide (NIMED)

Lumiracoxib (PREXIGE)

19981998 20052005

20062006 20082008

DILARANG BEREDAR :DILARANG BEREDAR : Insiden Kardiovaskular, Hepatotoksisk Insiden Kardiovaskular, Hepatotoksisk

dan Ulkusdan Ulkus

Tidak mendapatkan

persetujuan FDA

DITARIK dari market

DITARIK dari market

Tidak mendapatkan persetujuan FDA

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http://pfizer.com/files/products/http://pfizer.com/files/products/uspi_celebrex.pdfuspi_celebrex.pdf

- BLACK B

OX

WARNING -

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Copyright ©2007 American Heart Association

Antman, E. M. et al. Circulation 2007;115:1634-1642

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Copyright ©2007 American Heart Association

Antman, E. M. et al. Circulation 2007;115:1634-1642

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ULTRACET direkomendasikan untuk pasien OA dengan resiko kardiovaskular, renal dan

gastrointestinal

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005

Paracetamol up to 4g/day

Gastrolintestinalrisk

Renal risk

Cardiovascularrisk

Avoid NSAIDs/COX-2 inhibitors

Long termFlares

• Paracetamol / tramadol weak opioid compinations*

• Tramadol• Strong opioid

Moderate

Severe

COX-2 inhibitor

NSAIDs+PPI

Paracetamal /Tramadol

•Tramadol•Strong opioids

* 2nd choice

2006 New Guideline in Treatment Moderator- to-Severe Pain in OA patients with Risk Factors

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ULTRACET direkomendasikan untuk jangka panjang pada pasien usia lanjut dengan Low

Back Pain

ULTRACET efektif untuk nyeri neuropatik dan nosiseptik

Clinical Rheumatol (2006) 25 (Suppl 1): S22-S29

Nociceptive +/- neuropathic pain

Young / HealthyElderly

• Weak opioid combinations eg. Paracetamol / tramadoll

•Tramadol

• Strong opioid

Moderate

Severe

• COX-2 inhibitors /NSAIDs low dose) +/or paracetamol/ tramadol (NSAIDs-sparing)

•Tramadol*

•Strong opioids IR

Long term

WGPM ( The Working Group on Pain Management ) Recommendation at the 2nd meeting in EULAR 2005

2006 New Guideline in Treatment Moderator-to-Severe Low Back Pain

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ULTRACET efektif untuk SEGALA JENIS NYERI ULTRACET efektif untuk SEGALA JENIS NYERI dengan 4 mekanisme kerja yang unikdengan 4 mekanisme kerja yang unik

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ULTRACET terbukti memiliki efektivitas setara dengan kodein/parasetamol

Smith AB, et al. Am J Surg. 2004;187:521

1.7

1.5

1.0

1.5

2.0

Ultracet(n = 98)

Kodein/parasetamol(n = 109)

1 – 6 Hari

Skala pengurangan Nyeri: Complete = 4A lot = 3Moderate = 2Slight = 1None = 0 Worse = –1

Rata-rata pengurangan nyeri perhariPasca orthopedi & abdominal (hernia)

Pe n

gu

ran

ga n

Ny e

r i

Ha r

i an

P = 0.072

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Combination analgesia in 2005—a Combination analgesia in 2005—a rational approach: focus on rational approach: focus on

paracetamol–tramadolparacetamol–tramadol Journal Clinical Rheumatology Issue Volume 25, Supplement 7 / July, 2006 Abstract A multimodal (or balanced) approach to anaesthesia is a familiar concept that

offers important benefits in the management of both acute and chronic pain. Rational combinations of analgesic agents with different mechanisms of action can achieve improved efficacy and/or tolerability and safety compared with equianalgesic doses of the individual drugs. Combining different agents also enhances efficacy in complex pain states that involve multiple causes. Combinations of paracetamol plus a weak opioid agent are widely used. One such combination, paracetamol plus tramadol, exploits the well-established complementary pharmacokinetics and mechanisms of action of these two drugs. This combination has demonstrated genuine synergy in animal studies and also combines paracetamol’s rapid onset of efficacy with tramadol’s prolonged analgesic effect. Numerous studies have confirmed the efficacy and tolerability of paracetamol plus tramadol in both acute and chronic pain. As a single-dose treatment for acute post-operative pain, this combination delivers rapid and sustained pain relief that is greater than either agent alone. There is also extensive evidence for efficacy in the long-term management of chronic pain conditions, including osteoarthritis, low back pain and fibromyalgia. In the setting of chronic pain, paracetamol plus tramadol has shown sustained efficacy, safety and tolerability for up to 2 years without the development of tolerance. The efficacy of this combination has been demonstrated as well in respect to reduction of pain intensity and, more importantly, with regard to improvement of function and quality of life and the reduction of disability. Comparative trials have shown that paracetamol plus tramadol has comparable efficacy to paracetamol plus codeine, but with reduced somnolence and constipation compared with the codeine combination. The paracetamol plus tramadol combination is also free of organ toxicity associated with selective and non-selective non-steroidal anti-inflammatory drugs. Hence, paracetamol plus tramadol offers an effective and well-tolerated alternative to anti-inflammatory drugs or other paracetamol plus weak opioid combinations.

There is also extensive evidence for efficacy in the long-term management of chronic pain conditions, including osteoarthritis, low back pain and fibromyalgia.

In the setting of chronic pain, paracetamol plus tramadol has shown sustained efficacy, safety and tolerability for up to 2 years without the development of tolerance.

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ULTRACET ULTRACET CAN RELIEF THE PAIN WITHOUT FURTHER DAMAGECAN RELIEF THE PAIN WITHOUT FURTHER DAMAGE

Ultracet AMAN dan EFEKTIF digunakan jangka panjang (2 tahun)

Ultracet direkomendasikan oleh EULAR dan AHA untuk pasien dengan resiko kardiovaskular, renal dan gastrointestinal

Ultracet EFEKTIF untuk SEGALA JENIS NYERI (nyeri neuropatik dan nosiseptik)

Ultracet, ANALGESIK KUAT dengan EFEKTIVITAS setara dengan kodein/parasetamol

Treat the pain!Treat the pain! Nyeri adalah kondisi yang kompleks karena penyebabnya

yang beragam dan multi faktorial

Kombinasi analgesik merupakan langkah yang tepat karena dapat meningkatkan efektifitas dan tolerabilitas

Ultracet adalah analgesik fixed kombinasi dengan 3 mekanisme kerja berbeda yang mampu memblok nyeri secara sinergis.

Berdasarkan data klinis yang ada, Ultracet terbukti efektif untuk mengatasi nyeri nosiseptik dan neuropatik dengan kekuatan yang setara dengan Kodein/Parasetamol.

Penambahan Ultracet pada pasien OA yang telah menggunakan NSAID/COXIB, memberikan penurunan nyeri yang lebih baik lagi.

Ultracet terbukti efektif dan aman pada penggunaan jangka panjang tanpa menimbulkan toleransi

Treat the pain!Treat the pain!

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- Thank - Thank you -you -