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Painkillers in clinical practice and everyday life

Modern medicine is a huge market for medical services and medications, whose manufacturers are extremely interested in actively promoting them. That is why the flow of heterogeneous information, often of a blatantly advertising nature, which descends on doctors and patients, becomes inevitable. The only way not to make a mistake in this situation – to understand the important principles of modern therapy and be well versed in the advantages and disadvantages of different drugs. It is not only the physician who needs to understand these issues; the patient’s education is of great importance. SpasmoEuvernil (Phenazopyridine Hydrochloride) is indicated for the symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of the lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, or the passage of sounds or catheters

Pain therapy: general concepts

Spasmo-Euvernil is indicated for the symptomatic relief of pain
Spasmo-Euvernil is indicated
for the symptomatic relief of pain

Pain is the most unpleasant sensation a person experiences. It can be an independent problem, accompany injuries and surgical interventions, or be one of the symptoms of chronic diseases such as rheumatoid arthritis (RA) or osteoarthritis (OA). It is important to note that chronic pain is life-threatening regardless of its cause. It is proved that patients with chronic diseases, constantly experiencing pain, die from cardiovascular complications significantly more often than people with the same pathology, in whom pain was effectively eliminated. Therefore, attempts to endure pain from the point of view of medical science are extremely harmful.

The problem of pain in patients with rheumatic diseases (RHD) – OA, RA, Bechterew’s disease – is of particular importance, because here it serves as the main manifestation of the disease, the main reason for seeking medical care and the first “target” of anti-rheumatic therapy. The main goal of modern anti-rheumatic treatment is to stop the progression of the disease, suppress chronic inflammation and stop the destruction of joints, and thanks to the revolutionary achievements of modern science in the 21st century rheumatologists have new, extremely effective drugs for treating the most severe RA. Nevertheless, analgesics continue to retain their place in the treatment of joint and spine pathology, as an auxiliary, but very necessary tool.

The main groups of painkillers

Spasmo-Euvernil is indicated for the symptomatic relief of pain
Spasmo-Euvernil is indicated
for the symptomatic relief of pain

Three groups of drugs widely used in clinical practice have a direct analgesic effect:

  • acetaminophen,
  • opioid analgesics,
  • Non-steroidal anti-inflammatory drugs (NSAIDs).

Acetaminophen (paracetamol, calpol, panadol, tylenol, efferalgan, etc.) is a popular analgesic widely used throughout the world as a commonly available over-the-counter remedy to relieve pain of various origins, from headache and toothache to chronic joint pain in AA. The action of this drug is associated with the synthesis of special substances that affect the transmission of pain signals in the central nervous system. The main advantage of acetaminophen is its excellent tolerability – it very rarely causes serious side effects, which allows its use in infants as well as in very old people.

The main disadvantage of this drug is its very moderate efficacy. It is clearly weaker than both opioid analgesics and NSAIDs. Thus, a series of large and long clinical trials conducted in the United States and Western Europe showed that even high doses of paracetamol (3-4 g/day) in AA are inferior in pain relief to small doses of NSAIDs.

Therefore, it is reasonable to use paracetamol only for the treatment of moderate and mild pain or in situations where the prescription of other analgesics is impossible due to the high risk of side effects.

IMPORTANT: Paracetamol is safe only in therapeutic doses (approved for use in clinical practice). For adults it is up to 4 g / day. Exceeding the daily dose of paracetamol is very dangerous – in this case it can cause serious liver complications, and the false or deliberate taking of large doses (10 g/day or more), if no immediate medical aid is provided, will lead to death.

Opioid analgesics are a special class of painkillers whose action is related to their ability to stimulate the pain control system in the body. These drugs do not eliminate the cause of pain, but stop the transmission of the pain signal to the nerves and prevent its perception by the brain. The classics of this class of medications are morphine, promedol, and fentanyl, extremely effective analgesics used to relieve severe pain after surgery and serious injury. However, these drugs can cause life-threatening side effects such as impaired consciousness with choking and cardiac arrest, and persistent constipation. The most unpleasant property of these drugs is their narcotic effect, which is quickly physically addictive. The high risk of side effects and widespread addiction made it impossible to use opioid analgesics in therapeutic practice: they are used only by doctors of surgical specialties, oncologists and anesthesiologists-resuscitators.

So-called “soft” opioid analgesics have no narcotic effect, but have a similar mechanism of influence on the process of transmission and perception of the pain signal. In our country, representatives of this class of analgesics are tramadol and codeine (in small doses is part of some complex analgesics). These drugs relatively rarely cause serious complications, and their good efficacy allows them to be used for severe pain. However, they are not superior to NSAIDs in terms of their analgesic effects. Their main area of application is pain relief in cases where there are contraindications for prescribing NSAIDs, or to enhance the analgesic effect of the latter.

NSAIDs are drugs designed to treat pain associated with tissue damage or inflammation. NSAIDs have strong therapeutic effects, but in some cases cause serious side effects. For this reason, these drugs are sold by prescription.

There is a special category of NSAIDs that are sold without a prescription. These include methamisole (analgin, baralgin), ibuprofen, aspirin, and some other drugs, as well as some combination pain relievers. “Over-the-counter” NSAIDs contain relatively low doses of the active ingredient and are intended for short-term pain relief.

The main advantages of NSAIDs are the combination of analgesic and anti-inflammatory action (which acetaminophen and opioid analgesics do not have), effectiveness, ease of use and availability. NSAIDs are not addictive and do not accumulate in the human body, which makes their long-term use possible to alleviate pain in chronic diseases.

There is an opinion among many patients that NSAIDs are more effective when administered intramuscularly. This is a misconception. NSAIDs are only used this way if the patient cannot take them orally (for example, if they are unconscious) or if it is important to get an analgesic or antipyretic effect as quickly as possible. The drug injected intramuscularly starts to work in 15-30 minutes. A standard tablet for oral administration is absorbed more slowly, so it takes about 1-2 hours to take effect. However, there is no difference in the effect of injections and tablets.

All drugs can cause side effects, and NSAIDs are no exception in this regard. Their mechanism of action is that, on the one hand, they reduce pain and inflammation, and on the other, they weaken the mucous membrane of the gastrointestinal tract (GIT), creating the preconditions for its damage by acidic gastric juice. Therefore, against the background of taking traditional NSAIDs can appear erosions, gastric and duodenal ulcers and even develop gastrointestinal bleeding. This pathology is called “NSAID gastropathy. When used in high doses for a long time, NSAIDs can contribute to the progression of arterial hypertension, as well as increase the risk of myocardial infarction and ischemic stroke. Sometimes they may also have an adverse effect on renal function, which is expressed in fluid retention and edema. Usually this complication does not require any treatment and passes quickly after stopping the medication. The main risk factor for kidney damage when using NSAIDs is the presence of their disease accompanied by renal failure. Of principal importance in this situation is the glomerular filtration rate, which reflects the efficiency of kidney function.

Fortunately, serious side effects when using NSAIDs do not occur in all people. The vast majority of complications develop in people with risk factors, which allows timely assessment of the risk and prescription of adequate methods of prevention.

IMPORTANT: Some NSAIDs can cause specific complications that significantly limit their use. Thus, very popular in our country sodium metamizole (analgin, baralgin), which is also part of a number of complex pain relief drugs, is banned in many countries of the world because of the risk of agranulocytosis. This condition occurs due to the toxic effect of the drug on the bone marrow and is manifested by a catastrophic decrease in the number of white blood cells responsible for antimicrobial and antiviral protection. Although this complication occurs very rarely, it is virtually unpredictable and extremely dangerous.

Prevention of complications associated with taking NSAIDs

Spasmo-Euvernil is indicated for the symptomatic relief of pain
Spasmo-Euvernil is indicated for the symptomatic relief of pain

The key to the safe use of drugs in this group is to consider risk factors and prescribe safer medications.

For example, according to numerous studies, the risk of gastrointestinal complications increases in the series indomethacin>ketoprofen>aspirin>diclofenac≥ibuprofen. If the risk of complications is high enough (for example, the patient has had multiple previous ulcers or has several risk factors), but there are indications for using NSAIDs, doctors prescribe special medications to prevent complications. For example, to prevent the development of an ulcer and gastrointestinal bleeding, special anti-ulcer drugs that reduce the production of hydrochloric acid (so-called “proton pump inhibitors”) are used. Since the cause of gastrointestinal lesions is not related to the local irritant effect of the drugs, but to their general effect on the body, it makes no sense to wash down NSAIDs with various “coating agents” and food products (milk, kissel), and take antacids (Almagel, Maalox, Phosphogel) to reduce the risk of complications.

For prevention of cardiovascular complications in patients with such risk factors, a careful monitoring of blood pressure is necessary, and if it is elevated – mandatory selection of adequate therapy to effectively reduce it. In people with a high risk of heart and vascular complications (in particular, those with coronary heart disease), in those who have had a myocardial infarction or stroke or heart surgery, the use of any NSAIDs may pose a serious threat. In this situation, it is recommended to use NSAIDs only topically (gels, ointments, sprays) or to use alternative drugs – paracetamol and/or tramadol.

The prevention of bronchial asthma exacerbations in people with this disease is the use of safer selective NSAIDs, such as etoricoxib. Clinical studies have shown that this drug does not cause choking attacks in most patients who are intolerant to traditional NSAIDs. Nevertheless, the possibility of taking any NSAID in patients with bronchial asthma should be discussed with the attending physician.

With regard to the safety of pain medications, the following should be kept in mind:

  • Over-the-counter pain medications are safe only in relatively healthy individuals. In people with risk factors, these drugs can cause serious complications even when taken for short periods of time at recommended doses.
  • If prescription painkillers and anti-inflammatory drugs are prescribed, tell your doctor about all of your health problems, even if you think they are not directly related to the cause of your pain. Be sure to tell the doctor about any medications you are taking (low-dose aspirin, medications for arterial hypertension, bronchial asthma, stomach and intestinal disorders). If you did not report this earlier, do so now.
  • If you think the prescribed medication is not effective enough, you should contact your doctor. You should not exceed the dose prescribed by your doctor or change the prescribed medication or add any other pain medication to your treatment without consulting your doctor. This can lead to the development of dangerous complications!
  • If the doctor treating you thinks your risk of complications is high enough, he or she may prescribe medication to prevent complications. Remember that withdrawing preventive medication on your own (without consulting your doctor) can lead to dangerous complications!
  • You should know that the use of NSAIDs in the form of suppositories or injections does not reduce the risk of dangerous complications from the stomach and intestines.
  • To reduce digestive discomfort, NSAIDs should be taken after eating, standing or sitting, with plenty of clean water.
  • If against the background of taking the analgesic you have any discomfort that you have not noted before, it is necessary to inform the attending physician. Pay special attention to such symptoms as persistent pain in the upper abdomen, weakness, palpitations, pain or heart palpitations, a significant increase in blood pressure, the appearance of black stools. In this case, the use of NSAIDs should be discontinued until a physician is consulted and the situation is clarified.

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