Practical Management Of Osteoporosis

Transcription

1 Practical Management Of Osteoporosis CONFERENCE 2012 Education Centre, Bournemouth.19 November The following companies have given funding towards the cost of this meeting but have no input into the agenda or content. Staff from these companies will be present at the meeting and may have a stand promoting their products:

2 DR KAREN MOUNCE 12 TH NOVEMBER 2012

3 Pain and pain management Acute pain Analgesic ladder Neuropathic pain Analgesics Osteoporotic vertebral fractures

4 Acute o 6 weeks then sub-acute o Injury/tissue damage/inflammation/nociceptive o Vigilance/fear of injury Chronic o 3 months or more o Altered pain processing o Injury healed, persisting brain and nerve changes Neuropathic o Nerve injury/damage

5 Managing the intensity and effects of pain. o Physical and emotional experience Pharmacological Non-pharmacological o TENS, acupuncture o Physical therapies and exercise o Relaxation, mindfulness, stress reduction, distraction o Behavioural and adaptive therapies o Specialist procedures; injections, surgery Holistic assessment of person and preferences

6 Persistent pain from fracture o Pain mechanisms o Retropulsed fragment causing nerve or cord irritation Mechanical Pain o Pressure on facet joints o Strain on surrounding tissues o Altered forces Postural pain o Increasing kyphosis

7

8 Damaged tissue releases chemicals o Prostaglandins, H+ ions, ATP, bradykinin, 5HT, TNF Sensitises C fibres, slow pain fibres, o substance P, CGRP leads to release of histamine. Greater messaging, number, persistence and prolonged o Pain builds over hours. Blood vessels form leading to swelling, warmth and tenderness.

9

10

11

12 WHO developed for cancer pain, now general use Gradual increase/titration to pain intensity Appropriate drug, correct dose Efficacy V adverse effects Acute V chronic pain

13

14 Simple analgesics are Paracetemol and non steroidal anti-inflammatory drugs NSAIDs o Eg. Ibuprofen, Naprosyn, Diclofenac Adjuvant drugs are those developed for other conditions but have been found to have an effect on pain; o Anti depressants, Amitriptyline, duloxetine, citalopram o Anti epileptics, Gabapentin, Carbamazepine Advice is to use regularly by the clock o Not waiting until the pain is severe Emphasis on multiple drugs with different actions

15 Start with non-opioid analgesia o Paracetemol, aspirin, NSAIDS Give regularly and use adjuvants if necessary o Anti-depressants, anti-epileptics, steroid, muscle relaxants Step 2 mild opioids: with or without non-opioid o Codeine [7% population unable to metabolise to Morphine] o Dihydrocodeine, 4 hourly, mild to moderate pain, too constipating for long-term use.

16 Step 3 strong opioids Moderate to severe pain Fear of addiction affects prescribing and concordance Side effects o Nausea, vomiting, constipation, drowsiness, hypotension, respiratory depression. o Detachment and euphoria can be helpful. Lowest dose to prevent pain and add non-opioids if helpful Titrate on response. Remember renal function!

17 Tramadol acts on adrenergic and serotonin pathway as well as opioid receptors. o Less side effects reported. o Psychiatric and epileptic reactions reported o Withdrawal can be a problem Buprenorphine o Longer half life o Sublingual and patches o Partial agonist Tapentadol; weaker opioid plus noradrenaline pathway.

18

19

20 First line: Pregabalin 150mgm/day 600mgm or Amitriptyline 10mgm 75mgm. Except diabetic neuropathy start duloxetine 60mgms/day 120mgm/day Second line; Switch or add to with amitriptyline or Pregabalin, with duloxetine switch or combine with Pregabalin. Third line: Add or replace with Tramadol.

21 Works for pain relief and temperature Active in brain and brain stem Can be used WITH other tablets Increases efficacy of opiates Maximum 8 per day Frequently used as a combination tablet o Co-codamol, codydramol, tramacet

22 Many work as anti inflammatory, analgesic and anti pyretic drugs. Can be bought over the counter; ibuprofen Risks increase with dose increase o Cox 2 selective, low dose ibuprofen Active in tissues and in dorsal horn of spinal cord. Should be taken with food, with fluid, upright.

23 Risk of oesophageal and gastric erosions and ulcers. Check patient s medical history; o GI bleeds, BP, IHD, CRF Co prescribe stomach protector PPI Interacts with Warfarin May o increase blood pressure, ankle swelling o Decrease renal function, acute and long term effects Increased risk heart disease and stroke in longer term use

24 Assess Discuss treatment and side effects Agree short and long term goals Start and treat side effects Unmanageable, try changing opioid Monitor for tolerability and efficacy Review regularly Beware repeats at decreasing intervals, lost prescriptions, dose escalation, missed appointments. NB Opioid induced pain.

25 Acute injury pain usually more with severity of fracture Many fractures do not present to health care. o 26% prevalence in over 50s o 2 ½ times more likely to report back pain limiting activity/bed days for 10 days per year [Nevitt 1998] Increased mortality rate men>women o 15% population based survey [Cooper C] 1993 o 200% age matched controls [Lau E 2008] o Survival following diagnosis at 1 year; 53.9% Multiple fractures lead to poor posture, pain, deformity

26 Analgesia o Adequate o Encourage activity as soon as possible o Consider DVT if immobile Calcitonin: outside licence o Efficacy in reducing pain and improving mobility o All methods delivery [Blau L 2003]

27 Vertebroplasty and Balloon Kyphoplasty o Injection of cement into vertebra or balloon within vertebra. o Initial evidence was instant pain relief and reduction of further fractures o Some risks with cement invading spinal column o Subsequent independent trials v placebo show no benefit. [Kallames D 2009, Gangi A 2010] o Increased risk of new fracture in adjacent vertebra if cement enters disc space. Facet joint injection at fracture level o Steroid and anaesthetic o Benefit 33% patients [Wilson D 2001]

28

29 Acute pain from vertebral fractures. Beware complications Use analgesic ladder. Beware side effects Monitored use of opiates Calcitonin injections Referral for o Facet injections o Balloon kyphoplasty