Thread by @Drug_Evidence

THREAD: Painful Evidence: Do Common treatments for pain work❓

1/10 How effective are pain drugs? 🤔

In BC 120,000 ppl take cyclobenzaprine; 160,000 take gabapentin or pregabalin. Many others take duloxetine, venlafaxine, or amitriptyline

#MedEd #TIEvidence #painmanagement

2/10 SIDE EFFECTS:

Most 👨🧕on gabapentin/pregabalin/duloxetine/TCAs (e.g. amitriptyline) experience some adverse side effects like sleepiness, dizziness, nausea, dry mouth or constipation

Benefits/harms here: ti.ubc.ca/letter96

#MedEd #painmanagement

3/10 COCHRANE pain meds EVIDENCE:

Evidence frm 8 @cochranecollab reviews should ↘️ expectations abt likelihood+size of pain relief frm gabapentin, pregabalin, duloxetine, venlafaxine, amitriptyline, nortriptyline, imipramine, desipramine

ti.ubc.ca/letter96

#painmanagement

4/10 POOR ODDS:

At best,1 in 10 people taking either gabapentin, pregabalin, duloxetine, venlafaxine, amitriptyline, nortriptyline, imipramine or desipramine can be expected to report meaningful pain ↘️

ti.ubc.ca/letter96

#MedEd #painmanagement

5/10 WHEN WILL I KNOW?

Pts will feel the effect of these 💊 w/in 1-2 days at any dose.

If pain not better by 5-7 days, consider 🛑 tx and try something else.

Resist the urge to add new 💊 to drugs that are not working

#MedEd #painmanagement

6/10 LESS is MORE:

↗️ 💊 unlikely to ↗️ likelihood of pain relief.

Example: doses ↗️ than 1200mg/d gabapentin or 300mg/d pregabalin unlikely to produce more pain relief

Higher doses ⬆️ risk of adverse events:
ti.ubc.ca/letter117

#MedEd #painmanagement #ptsafety

7/10 Gabapentin 💊CAUTION ⚠️

Use particular caution for ppl at risk of cognitive impairment, balance disturbance, falls, or when edema is undesirable (e.g. peripheral vascular disease in the elderly)

#MedEd #painmanagement #ptsafety

8/10 PROMOTING OFF-LABEL USE:

Misleading promo of off-label use pushed gabapentin to blockbuster status even though scientifically the 💊 only had minor role in pain control

Evidence: ti.ubc.ca/letter75
Misleading promotion: bit.ly/2XVncU4

#MedEd #painmanagement

9/10 CYCLOBENZAPRINE is a potent anticholinergic

⌚️ for obvious & subtle anticholinergic effects:

Example: dry mouth impairs speech + swallowing and causes 🦷 decay

Remember eyes, bladder, bowel, brain

ti.ubc.ca/letter105

#MedEd #painmanagement

10/10 ASSESS & REASSESS

To identify patients who respond, a therapeutic trial with early assessment is essential

Reassessment is needed to detect people with spontaneous remission or placebo response

ti.ubc.ca/letter96

#MedEd #painmanagement

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