Home' Australian Pharmacist : Australian Pharmacist March 2014 Contents Australian Pharmacist March 2014 I ©Pharmaceutical Society of Australia Ltd. 37
The potential adverse reactions of NSAIDs
and COX-2 inhibitors are well known.
Side effects include gastrointestinal
irritation and bleeds, acute renal failure,
and precipitation of heart failure.
Guidelines for the management of
persistent pain in older adults generally
recommend against using NSAIDs and
COX-2 inhibitors, particularly in view of
the substantial evidence that paracetamol
offers a similar level of analgesia
without the elevated risk of adverse
reactions.1,5--7,14,15,20 In most non-palliative
care settings, oral NSAIDs and COX-2
inhibitors should be avoided in elderly
adults.1 If NSAIDs/COX-2 inhibitors are
considered appropriate, the following are
recommendations for their use in treating
persistent pain in the elderly6:
• Use NSAIDs that have a short half-life.
• Use the smallest possible dose for the
shortest possible duration.
• Do not combine COX-2 inhibitors with
• Concomitant use of NSAIDs or COX-2
inhibitors and aspirin may block the
cardioprotective effect of aspirin.
• If effective pain reduction is not
observed within the first few days of
treatment, consider an alternative
Topical NSAIDs, such as diclofenac,
have been used in hopes of averting
systemic NSAID-related adverse effects.
These agents appear to be safe and
potentially effective for the short-term
management (up to 4 weeks in many
studies) of localised musculoskeletal pain.5
Adjuvants (e.g. anticonvulsants or
tricyclic antidepressants) are often
useful in patients with neuropathic pain.
There is increasing use of gabapentin
and pregabalin in the management of
neuropathic or mixed pain in the elderly.
Caution is necessary with the tricyclic
antidepressants due to the potential
for drug interactions and adverse
reactions (e.g. postural hypotension or
urinary retention). Apart from its cost,
the biggest limitation with the use of
gabapentin in older individuals is its slow
titration process and dosing schedule.
An adequate trial can take two months
or more because it requires that patients
are on effective doses for at least two
weeks.1 Pregabalin has a much simpler
dosing and titration schedule. Frail
older patients should be started with
50 mg at bedtime. Other older patients
can be started at 75 mg twice a day and
increased to an effective dose, likely
to be between 150 mg/day and 600
mg/day. An adequate trial takes one
month. The major side effects with both
gabapentin and pregabalin are sedation
and dizziness, which can be hazardous in
Non-pharmacological methods of
pain control, such as acupuncture,
breathing exercises, music, application
of heat or cold, physical therapy
and transcutaneous electrical nerve
stimulation (TENS), can be helpful when
used either alone or with analgesics.
They are particularly valuable in the
elderly because they can reduce the need
for analgesic medicines that carry the risk
of interactions and adverse effects.7,15,20
There needs to be realistic expectations
of the outcomes of analgesic therapy
for chronic pain. This generally does not
mean the total absence of pain around
the clock. Instead, enhanced daily
functioning with tolerable pain may be
the best outcome.34 In fact, older people
treated for chronic pain often show a
more dramatic improvement in function
than level of pain.20 Complete pain relief
is rarely achievable when dealing with
pain of neuropathic origin.15
Pharmacists should recognise and
discuss potential or likely side effects
such as constipation when using opioids.
In addition, if patients demonstrate a
reluctance or fear of opioids, then the
pharmacist should help allay those fears
with thorough counselling. In the case of
aged care residents, pharmacists should
endeavour to identify triggers that may
suggest pain control is not optimal
(e.g. increasing use of sedatives and
anti-psychotics, increase in frequency for
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