27
Volume3 Issue3
|
I
ssues and
P
eople
WithNSAIDs, it’s important to takeagooddrughistory. If apatient is takinganticoagulants, likewarfarin, there is
an increased riskof a longgastrointestinal (GI) bleed. Similarly, patientswhoareon serotonin selective reuptake
inhibitors (SSRIs) for depressionhavean increased riskofGI bleedwithNSAIDs. NSAIDs shouldalsobeavoided in
patientswith known renal dysfunction.
➲
When ibuprofendoesn’twork
CL:
If ibuprofenalonedoesn’t relieve thepain,wecanalternate600mg ibuprofenwith1000mgof
acetaminophen.
BC:
It’swell known thatNSAIDshaveaceilingeffect, soyou’reonlygoing tobeable todrawmoderatepaindown
byabout 50%; addingacetaminophen to that regimenona regular basiswill raiseyour ceilingandgiveyouan
additional reduction inpain. Theycanbegiven together, or theycanbealternated.
➲
Concerns about acetaminophen
BC:
Oneof thebigconcerns is that acetaminophencancauseacutehepatotoxicity, andwhenpeopleare inpain,
theymay tend tooveruseacetaminophen. It shouldbeclearlypointedout that they shouldnot takemore than
4gper day—that’s 8dosesof 500mgacetaminophen (e.g., Tylenol®).
➲
Steroids as an adjunct
CL:
A steroidcanbeconsideredas anadjunct tousewithnon-opioidanalgesics for reducing swellingandpain
postoperativelywithnohigher riskof infectionandminimum riskof sideeffects—and it decreases theneed for
post-operativeanalgesics. Agood steroid touse isdexamethasone; the tradename inCanada isDecadron®.We
cangive4mgofDecadron® twiceaday for 2–3days.
➲
Opioids, third-linemedication
CL:
If thepatient hasmoderate to severepainand isnot being reasonablymanagedwith ibuprofen
or acetaminophen, thenyoucanconsider usinganopioid. Anopioid Iwoulduse for post-
surgical pain isoxycodoneusingadoseof 5–10mg. Percocet is acombinationof oxycodoneand
acetaminophen; 1–2 tablets canbe takenevery4–6hours.
BC:
The2most commonlyusedcombinationopiateproducts indentistryareTylenol 3
(acetaminophen, codeineandcaffeine) andPercocet. But in fact a lot of patientsdon’t get effective
analgesiawith theacetaminophencodeinecombination.
Theother problem is that about 20%of thepopulationdon’t adequatelymetabolizecodeine
or tramadol and thereforedon’t getmaximumeffect out of thesedrugs. In that case, if youare
consideringanopiate, it’sprobablybetter toconsider something likeoxycodone.
➲
On codeine
CL:
I amnot a fanof codeinebecause it doesnotworkwithacertainpercentageof the
populationandcanalsocausepatients tobe sick to their stomachandcauseconstipation.
BC:
I agree, I thinkwe should just avoidcodeineand stick todrugs likeoxycodone,whichare
more likely tobeeffective inall patients.
TowatchDrs. Chris Lee
andBrianCairnsdiscuss
useof opioids in the
management of acute
post-surgical painvisit:
oasisdiscussions.ca
2015/05/20/psp
and
oasisdiscussions.ca
2015/07/09/qa-2
Youwant to give enoughmedication that the patient ismanaged, without
giving toomuch. I tend to say1–2days of an opioid is reasonable and then
follow-upwith the patient if needed.
–Dr. Chris Lee
