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Kuningan, 9 April 2010. Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan kerusakan jaringan.

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Presentation on theme: "Kuningan, 9 April 2010. Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan kerusakan jaringan."— Presentation transcript:

1 Kuningan, 9 April 2010

2 Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan kerusakan jaringan atau diduga ada kerusakan jaringan  Nyeri adalah pengalaman sensorik yang berkaitan dengan aktivasi nociceptor dan lintasan nyeri  Nyeri adalah suatu pengalaman emosional  Kerusakan jaringan tidak mesti ada (International Association for the Study of Pain)

3 Examples Peripheral Post herpetic neuralgia Trigeminal neuralgia Diabetic peripheral neuropathy Postsurgical neuropathy Posttraumatic neuropathy Central Posts troke pain Common descriptors 2 Burning Tingling Hypersensitivity to touch or cold Examples Pain due to inflammation Limb pain after a fracture Joint pain in osteoarthritis Postoperative visceral pain Common descriptors 2 Aching Sharp Throbbing Examples Low back pain with radiculopathy Cervical radiculopathy Cancer pain Carpal tunnel syndrome Mixed Pain Pain with neuropathic and nociceptive components Neuropathic Pain Pain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system) 1 Inflammatory Pain Pain caused by injury to body tissues (musculoskeletal, cutaneous or visceral) 2 1. International Association for the Study of Pain. IASP Pain Terminology. 2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed ;11-57 JENIS NYERI

4 DiagnosisDrug Treatment Acute and chronic pain NSAIDS (al Meloxicam/ Movi-cox), Opioids, Paracetamol Myofascial pain dysfunction Analgesics (Movi-cox), tricyclics, centrally-acting muscle relaxants, glucocorticoids Neuropathic pain, neuralgias Carbamazepine, phenytoin, baclofen, tricyclics, gabapentin, others?

5 Ascending Pain Transmission Pathway The ascending neural pain pathway is only a 3 neuron relay The major convergence point is the ventral posterior lateral nucleus of the thalamus, which relays the signal to limbic and cortical areas Ascending Pain Pathway (Purves, 2001).

6 Descending Pain Modulation Pathway Descending pain pathway (Purves, 2001). The Descending Pain Pathway – The Periaqueductal Grey (PAG) is the major convergence point.

7 Targets of Pain Therapies Gottschalk et al., 2001 Alternative methods Acupuncture Physical Therapy Chiropractics Surgery Pharmacotherapy Non-opioid analgesics Opioid analgesics Nerve Blocks Adjuvant analgesics (neuropathic, musculoskeletal) Electrical Stimulation Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS) Acetaminofen (NSAID)

8 Thick, myelinated, fast conducting neurons Mediate the feeling of initial fast, sharp, highly localized pain. Very thin, unmyelinated, slow- conducting Mediate slow, dull, more diffuse, often burning pain. Rabaan Tekanan

9 Nerve Fibers ClassVelocityFunction A-  FastMotor A-  Fast Touch, pressure A-  Intermediate Muscle tone A-  Intermediate Pain, temperature BSmallMotor CSmallPain

10 Chemical mediators are released from damaged tissue and inflammatory cells. Some inflammatory mediators directly activate nociceptors, while others act together to sensitize the pain pathway.

11 Inflammation l biological response to injury or foreign substances l acute and chronic inflammation l components: cellular response biochemical mediators

12 Mechanisms of Inflammation Cellular Mechanisms: Acute inflammation l PMN Chronic inflammation l lymphocytes l monocytes

13 Mechanisms of Inflammation Biochemical Mediators l vasoactive amines l plasma proteases (complement, kinins) l arachidonic acid metabolites (PG, LT) l lysosomal constituents l oxygen derived free radicals l cytokines l growth factors

14 Mediators of Inflammation Arachidonic Acid Metabolites  Prostaglandins  Leukotrienes

15 Generation of Eicosonoids

16 Biological Effects of Prostaglandins


18 Non-COX selective inhibitors of cyclooxygenase Selective COX-2 inhibitors Leukotriene inhibitors

19 Non-COX Selective NSAIDs l Carboxylic acids [salicylates, meclofenamate, diflunisal] l Indoleacetic acids [indomethacin, sulindac] l Propionic acids [ibuprofen, fenoprofen, ketoprofen, flurbiprofen] l Naphthalene acetic acids [naproxen]

20 Non-COX Selective NSAIDs [cont’d] l Diclofenac l Etodolac l Nabumetone l Oxaprozin l Ketorolac

21 COX - 2 Inhibitors l Celecoxib l Rofecoxib l Valdecoxib l Meloxicam (Movi-cox)* *[less COX-2 selective]

22 Golongan Coxib resiko kardiovaskuler + stroke  Physicians prescribing celecoxib or valdecoxib should consider the emerging cautionary data "when weighing the benefits against risks for individual patients." The most appropriate candidates for coxib therapy are patients at a high risk of GI bleeding or who have a history of intolerance to "or are not doing well on" nonselective NSAIDs.  "Individual patient risk for cardiovascular events and other risks commonly associated with NSAIDs should be taken into account for each prescribing situation."  Consumers should use all over-the-counter analgesics, "including NSAIDs," strictly according to the label instructions and consult a physician if using them for longer than 10 days.

23 Justification for the Development of COX-2 Selective Inhibitors

24 COX-2 Selectivity: Molecular Basis

25 OH O O O N S NHNHNHNH CH 3 NPiroxicam OHO OO N S NHNHNHNH N S Meloxicam Celecoxib NH 2 S O O N N CF 3 H3CH3C OXICAMSCOXIBS Chemical Structures of Oxicams and Coxibs Rofecoxib Linear, enolic acidY-shaped, Tricyclic O O O CH 3 S O

26 COX-2 Selectivity

27 Efficacy as an emerging concern of NSAID used  Potency (strong)  Onset of action (rapid)  Duration of action (long) Efek samping minimal Harga terjangkau

28 Meloxicam (MOVI-COX) was approved recently by the FDA for use in osteoarthritis. The recommended dose for meloxicam is 7.5 to 15 mg once daily for osteoarthritis and 15 mg once daily for rheumatoid arthritis. Meloxicam demonstrates roughly tenfold COX-2 selectivity on average in ex vivo assays. However, this is quite variable, and a clinical advantage or hazard has yet to be established. There is significantly less gastric injury compared to piroxicam (20 mg/day) in subjects treated with 7.5 mg/day of meloxicam, but the advantage is lost with 15 mg/day (Goodman & Gilman, 2006)

29 Potency of NSAID milligram basis of active compound for each formula potencyNSAIDmg/formula strongMeloxicam Piroxicam 7.5, 15 10, 20 Diclofenac25, 50, 75 moderateCelecoxib Nimesulide 100, Ketorpofen100, 200 weakMefenamic acid Naproxen 500 Nabumetone500

30 Onset of action of NSAID onsetNSAIDT-max (hr) RapidDiclofenac0.8 Nimesulide1.2 – 2.7 SlowCelecoxib2 – 4 Meloxicam6

31 Duration of action of NSAID durationNSAIDT-1/2 (hr) shortDiclofenac1.1 Nimesulide1.8 – 4.7 moderateCelecoxib11 Naproxen14 longMeloxicam20 Piroxicam57

32 Ototoxic Bronchospam CHF HepatotoxicUGIB Bleeding Nephrotoxic TocolyticAllergy Color blindness TOXICITY OF NSAIDs Mechanism of = Mechanism of therapeutic effects adverse effects Perdarahan GI

33 Treatment No. of patients Drug exposure (days) Patients/ byear No. of GI adverse events Percentage per 100 patients/year Placebo Meloxicam 7.5mg Meloxicam 15mg Meloxicam 22.5mg Diclofenac Naproxen Table IV. Incidence of gastrointestinal (GI) adverse events Efficacy and Tolerability of Meloxicam, a COX-2 Preferential Nonsteroidal Anti-Inflammatory Drug [Clin Drug Invest 22(12): , © 2002 Adis International Limited]

34 Kombinasi OAINS Kombinasi 2 OAINS:  Tidak dianjurkan  Efek samping meningkat  Tidak menambah efikasi Kombinasi OAINS dan Analgetik: Masih dapat dipertanggungjawabkan Kombinasi OAINS dengan Pelindung Lambung:  Ditujukan untuk sedikit mengatasi masalah efek samping terhadap lambung.  Dapat diberikan bersama golongan PPI, Misoprostol

35 NSAID +Acetaminophen  Greater analgesic effect than either alone  Avoids adverse effects of opioids  Similar half lives for many NSAIDS and acetaminophen  Over-the-counter  Each has analgesic ceiling.


37 Pain: A conceptual approach to treatment (Biopsycosocial approach) Pain Behaviors Suffering Pain Perception Nociception Local block NSAIDs (Movicox ® ) Surgery Physical modalities Opioid Adjuvants NSAIDs? Acetaminophene Neural augmentation Ablative surgery Anti-depressants / psychotropics Relaxation Spiritual Cognitive therapies Functional restoration 1. Looser JD, Cousins MJ. Med J aust 1990;216: ; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3. Mynors-Wallis L, et al. Br J Psychiatry. 1997;170: ; 4. Morley S, et al. Pain. 1999;80:1-13.

38 A namnesa nyeri secara sistematik dan teratur B erprasangka baik (percaya) terhadap keluhan pasien atau keluarga C arilah metode kontrol nyeri yang nyaman untuk pasien dan keluarga D ilakukan intervensi yang tepat waktunya, logis dan terkoordinasi E dukasi pasien dan keluarga untuk mengatasi nyeri sekuat mungkin


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