The Pain Source

The following information is NOT meant to be used to treat yourself or patients

Generic name= Etodolac

Image from Drugs.com

Trade name = Lodine

Class = anti-inflammatory

MOA

• Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins

Dosing

• 200, 300, 400, 500, 600-mg pills
• Typically prescription: 200-400mg TID or QID
• Max dose: Do not exceed 1200-mg/day

Note:

• COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds.
• Take with food or 8-oz of water
• May increase risk of cardiovascular thrombotic events, MI, and stroke
  • Consider avoiding in patients with cardiac history
• Absolute contraindication: ASA allergy
• Use with caution in renal and liver impairment

Related Content:

• Meloxicam – Mobic
• Ibuprofen – Advil, Motrin

The following information is NOT meant to be used to treat yourself or patients

• Generic name = Ketorolac
  

  Source: buyemp.com

• Trade name = Toradol
• Class = anti-inflammatory
• MOA
  • Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins
  • In vitro, ketorolac is the most COX-1 predominant NSAID (click here)
• Advantages
  • When used IM or IV, it is the go-to NSAID for acute relief of severe pain
• Dosing
  • Availability:  10-mg pills; 15, 30, 60-mg vials
  • Typically given as a one-time IM/IV dose of 60-mg or 30-mg, or multi-dosed as 30-mg IM/IV q6h or 15-mg q6h
  • If given as PO route, 10-mg PO q6h
  • Max dose: Do not exceed 120-mg IV/IM per day, or 40-mg PO per day
  • Max of 5 consecutive days
  • Renal insufficiency dosing:  15-mg IV/IM q6h; do not exceed >60-mg/day
    
  • Advanced renal impairment:  contraindicated
• Note:
  • COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds
  • Take with food or 8-oz of water
  • May increase risk of cardiovascular thrombotic events, MI, and stroke
    • Avoid in patients with cardiac history
  • Absolute contraindication: ASA allergy

Related Content:

• No Related Posts

Venlafaxine (Effexor)

• Uses(off-label) [2]
  • Neuropathic pain (diabetic neuropathy)
  • Migraines (prophylactic)
  • Tension headaches
  • Chronic pain syndromes
  • Fibromyalgia [1]
  • Chronic fatigue syndrome
• Increases serotonin much more than norepinephrine (S>>>NE)
  • 75mg BID is believed to only increase serotonin –> better for depression
  • 150-300mg/day (in BID or TID dosing) will increase both S and NE
• Dosing
  • Immediate-release formulation: Start with 37.5mg BID, and increase every 4-7 days (if tolerated) [max of 100mg TID]
  • Extended-release: Start 37.5 to 75mg daily, and increase by 75mg every 4-7 days [max of 225-mg]
  • Note: taper dose over 2-weeks to discontinue

Desvenlafaxine (Pristiq)

• The active metabolite  of venlafaxine.
• Not used as commonly in pain medicine

Duloxetine (Cymbalta)

• Uses(FDA-approved)
  • Diabetic painful peripheral neuropathy
  • Fibromyalgia
  • Major depressive disorder and generalized anxiety disorder
• The effectiveness in treating fibromyalgia are independent of whether the patient also has depression. (3)
• Thought to have a more NE reuptake effects than venlafaxine, but still less NE than S.   (S > NE)
• Dosing
  • Start with 60mg daily.
  • May be better to start with 30mg daily for a week to minimize side effects.
  • Taper dose gradually to discontinue
• Adverse effects
  • Weight gain (with long-term use)
  • Nausea (seen early in course, but tends to resolve)
  • Liver toxicity (in patients with pre-existing liver disease)
  • Increased blood pressure (because of the increase in NE reuptake)

Milnacipran (Savella)

• Uses(FDA-approved)
  • Fibromyalgia
  • Also used for major depressive disorder in other countries
• 3:1 norepinephrine to serotonin reuptake inhibition ratio (Note: this is the only SNRI which has more effect on NE reuptake than S) (NE>>>S)
• Dosing
  • Titrated up slowly to minimize adverse effects.
  • Starter pack includes pills for:  12.5mg x 1 day, then 12.5mg bid x 2 days, then 25mg bid x 4 days, then 50mg bid.  Max dose of 100mg bid.
  • Note: Many practitioners are now doubling the length of time to titrate up.  So, instead of 12.5mg for 1 day, they recommend 12.5mg for two days.  Therefore, instead of getting up to 50mg bid in 7 days, it would now take 14 days.
  • Taper dose gradually to discontinue
• Adverse effects(most common)
  • Nausea, headache, constipation, dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpitations, heart rate increase, dry mouth, and hypertension.
  • More caution with patients that are already hypertensive, because of the increased norepinephrine reuptake inhibition.
• Absolute contraindications
  • Migraine patients taking triptan medications (ex: sumatriptan, rizatriptan, zolmitriptan, etc)
  • Pregnancy
  • Caution with advanced renal disease (use a smaller dose)

Resources:

1) Venlafaxine Treatment of Fibromyalgia:  http://www.ncbi.nlm.nih.gov/pubmed/14565792

2) http://www.emedexpert.com/facts/venlafaxine-facts.shtml

3) http://www.emedexpert.com/facts/duloxetine-facts.shtml

Related Content:

• Milnacipran – Savella
• Venlafaxine – Effexor
• Duloxetine – Cymbalta
• Serotonin Syndrome
• Pregabalin – Lyrica

The following information is NOT meant to be used to treat yourself or patients.

• Generic name = Meloxicam
• Trade name = Mobic
  
• Class = anti-inflammatory
• MOA
  • Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins
    • Thought to inhibit COX-2 more than COX-1 (click here for a chart)
• Advantages
  • BID dosing
  • Inexpensive:  On the Target and Wal-Mart $4/month generic lists
• Dosing
  • 7.5, 15-mg tablets
• Note:
  • COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds
  • Take with food or 8-oz of water
  • May increase risk of cardiovascular thrombotic events, MI, and stroke
    • Avoid in patients with cardiac history
  • Absolute contraindications: ASA allergy, gastritis/ulcer, severe hepatic impairment, CABG

Related Content:

• Ibuprofen – Advil, Motrin
• Etodolac – Lodine
• VIDEO: Subacromial Bursa Injection under fluoroscopy
• VIDEO: Cervical Facet Injection
• Full Can Test

The following information is NOT meant to be used to treat yourself or patients

• Generic name = Diclofenac
• Trade name = Voltaren, Voltaren-XR, Voltaren gel, Arthrotec, Flector patch
• Class = anti-inflammatory
• MOA
  • Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins
• Advantages
  • Relatively inexpensive as generic
  • Comes in multiple formulations (pills, gel, patch)
• Dosing
  • 25, 50, 75-mg tablets
  • 100-mg extended release tablet
  • 25-mg capsule
  • 1% and 3% gel (Voltaren Gel)
    • Apply 2-grams (upper extremities) or 4-grams (lower extremities) to painful joint QID [no more than 8 or 16-gram/day to any single joint respectively]
    • How to measure and apply the gel
  • 1.5% topical solution
  • 180-mg patch (Flector patch)
    • One patch BID to most painful area (click here)
• Note:
  • COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds
    • Arthrotec is a combination with misoprostol (to protect the stomach)
  • Take with food or 8-oz of water
  • May increase risk of cardiovascular thrombotic events, MI, and stroke
    • Avoid in patients with cardiac history
    • The flector patch and topical formulations are great as alternatives for these patients
  • Flector patch- good for areas where local inflammatory relief is needed, but in patients who can’t take systemic NSAIDs
    • medium and large joints (examples: shoulder, sacroiliac, knee, ankle, elbow)
    • superficial painful tendons (examples: biceps tendon, DeQuervain’s, achilles)
  • Arthrotec gel
    • good for superficial, small joints and other small areas (ex: finger joints, tendonitis at wrist)
  • Absolute contraindication: ASA allergy

Related Content:

• Lateral Epicondylitis
• Pes Anserine Bursitis
• Naproxen – Aleve, Anaprox, Anaprox DS, Naprosyn, Naprelan
• Ibuprofen – Advil, Motrin
• VIDEO: Subacromial Bursa Injection under fluoroscopy

The following information is NOT meant to be used to treat yourself or patients

Generic name= Naproxen

Source: HealthSquare.com

Trade name = Aleve, Anaprox, Anaprox DS, Naprosyn, Naprelan

Class = anti-inflammatory

MOA

• Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins

Advantages

• Relatively inexpensive as generic
• Available OTC
• Least cardiovascular risk when using high-dose

Dosing

• 200, 220, 250, 275, 375, 500, 550-mg pills
• Comes in 200 and 220-mg over-the-counter [220 mg of naproxen sodium contains 200-mg naproxen]
• Typical dosing:
  • 250-mg PO q6-8 hrs prn
  • 500-mg PO q12 hrs
• Max dose: Do not exceed 1250-mg/day for more than a week

Note:

• COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds
• Take with food or 8-oz of water
• May increase risk of cardiovascular thrombotic events, MI, and stroke
  • Consider avoiding in patients with cardiac history
  • The above warning is with all NSAIDs.

Keep in mind that naproxen at a high dose (500mg BID) has NOT been shown to increase the risk of cardiac and cerebral events

• Absolute contraindication: ASA allergy
• Naprelan is a controlled-release formulation

Related Content:

• Lateral Epicondylitis
• Pes Anserine Bursitis
• Diclofenac – Voltaren, Voltaren-XR, Voltaren gel, Arthrotec, Flector patch
• Ibuprofen – Advil, Motrin
• VIDEO: Subacromial Bursa Injection under fluoroscopy

The following information is NOT meant to be used to treat yourself or patients

Generic name = Ibuprofen

Trade name = Advil, Motrin

Class = anti-inflammatory

MOA

• Blocks cyclooxygenase (COX-1 & COX-2) and thus production of prostaglandins

Advantages

• Relatively inexpensive as generic
• Available over-the-counter

Dosing

• 50, 100, 200, 300, 400, 600, 800-mg pills
• Comes in 200-mg pills over-the-counter
• For acute, short-term use, it is typically prescribed as 800-mg four times a day for a week
• Max dose: Do not exceed 800-mg/dose and 3200-mg/day for more than a week

Note:

• COX-1 normally produces prostaglandins that are gastroprotective.  Thus, blocking it can lead to gastric ulcers/bleeds.
• Take with food or 8-oz of water
• May increase risk of cardiovascular thrombotic events, MI, and stroke
  • Consider avoiding in patients with cardiac history
• Absolute contraindication: ASA allergy
• Use with caution in renal and liver impairment

Related Content:

• Lateral Epicondylitis
• Pes Anserine Bursitis
• Meloxicam – Mobic
• Diclofenac – Voltaren, Voltaren-XR, Voltaren gel, Arthrotec, Flector patch
• Naproxen – Aleve, Anaprox, Anaprox DS, Naprosyn, Naprelan

The following information is NOT meant to be used to treat yourself or patients

• Generic name = Carisoprodol (kar eye soe proe’ dole)
• Trade name = Soma
  
• Class = muscle relaxant
• MOA
  • Unknown
• Disadvantages
  • May cause dependence because of the metabolite, meprobamate
• Dosing
  • Strengths: 250, 350-mg
  • 350 mg tid and qhs

Related Content:

• Methocarbamol – Robaxin
• Metaxalone – Skelaxin
• Chlorzoxazone – Parafon Forte
• Baclofen – Lioresal
• Tizanidine – Zanaflex

The following information is NOT meant to be used to treat yourself or patients

• Generic name = Methocarbamol
• Trade name = Robaxin
  
• Class = muscle relaxant
• MOA
  • Unknown
  • General CNS depression
• Advantages
  • Relatively inexpensive
  • IM/IV options
• Dosing
  • 500, 750-mg pills
  • 1500-2000 mg PO q6 hours for 2-3 days, then 1000 mg qid
  • 500 mg PO qid in elderly (then titrate up as tolerated)
  • Max dose: Do not exceed 3000-mg/day for more than 3 days
• Note:
  • Avoid in renal dysfunction

Related Content:

• Carisoprodol – Soma
• Metaxalone – Skelaxin
• Chlorzoxazone – Parafon Forte
• Baclofen – Lioresal
• Tizanidine – Zanaflex

The following information is NOT meant to be used to treat yourself or patients

• Generic name = Metaxalone (me tax’ a lone)
  

  Photo from Drug3k.com

• Trade name = Skelaxin
  
• Class = muscle relaxant
• MOA
  • Thought to cause general CNS depression
• Dosing
  • 800-mg pills
  • 800 mg PO tid/qid
  • Adequate trial period:  2 weeks

Related Content:

• Carisoprodol – Soma
• Methocarbamol – Robaxin
• Chlorzoxazone – Parafon Forte
• Baclofen – Lioresal
• Tizanidine – Zanaflex