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Prima Resort Kuningan 9 April 2010. Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan.

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Presentasi berjudul: "Prima Resort Kuningan 9 April 2010. Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan."— Transcript presentasi:

1 Prima Resort Kuningan 9 April 2010

2 Definisi Nyeri (Pain) dari IASP Pain (Nyeri) adalah suatu pengalaman sensorik dan emosional yang berkaitan dengan kerusakan jaringan atau diduga ada kerusakan jaringan  Nyeri adalah pengalaman sensorik yang berkaitan dengan aktivasi nociceptor dan lintasan nyeri  Nyeri adalah suatu pengalaman emosional  Kerusakan jaringan tidak mesti ada (International Association for the Study of Pain)

3 Examples Peripheral Post herpetic neuralgia Trigeminal neuralgia Diabetic peripheral neuropathy Postsurgical neuropathy Posttraumatic neuropathy Central Posts troke pain Common descriptors 2 Burning Tingling Hypersensitivity to touch or cold Examples Pain due to inflammation Limb pain after a fracture Joint pain in osteoarthritis Postoperative visceral pain Common descriptors 2 Aching Sharp Throbbing Examples Low back pain with radiculopathy Cervical radiculopathy Cancer pain Carpal tunnel syndrome Mixed Pain Pain with neuropathic and nociceptive components Neuropathic Pain Pain initiated or caused by a primary lesion or dysfunction in the nervous system (either peripheral or central nervous system) 1 Inflammatory Pain Pain caused by injury to body tissues (musculoskeletal, cutaneous or visceral) 2 1. International Association for the Study of Pain. IASP Pain Terminology. 2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57 JENIS NYERI

4 Neuropathic PainMuscle/skeletal Pain Chronic pain (months/years)Acute pain (hours or days) Caused by injury or disease to nerves Caused by injury or inflammation that affects both the muscles and joints Mild to excruciating pain that can last indefinitely Moderate to severe pain that disappears when the injury heals Causes extreme sensitivity to touch – simply wearing light clothing is painful Causes sore, achy muscles Sufferers can become depressed or socially withdrawn because they see no relief in sight and may experience sleep problems Sufferers can become anxious and distressed but optimistic about relief from pain Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97; Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L. Cecil Textbook of Medicine. 21st ed; 2000

5 Symptoms of Neuropathic Pain Characterized Differently Neuropathic Pain Muscle/Skeletal Pain Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997; Galer BS et al. Diabetes Res Clin Pract. 2000;47:123-128






11 Nociceptive/ imflammatory/ musculoskletal pain Neurophatic pain

12 Thick, myelinated, fast conducting neurons Mediate the feeling of initial fast, sharp, highly localized pain. Very thin, unmyelinated, slow- conducting Mediate slow, dull, more diffuse, often burning pain. Rabaan Tekanan

13 Nerve Fibers ClassVelocityFunction A-  FastMotor A-  Fast Touch, pressure A-  Intermediate Muscle tone A-  Intermediate Pain, temperature BSmallMotor CSmallPain

14 Targets of Pain Therapies Gottschalk et al., 2001 Alternative methods Acupuncture Physical Therapy Chiropractics Surgery Pharmacotherapy Non-opioid analgesics Opioid analgesics Nerve Blocks Adjuvant analgesics (neuropathic, musculoskeletal) Electrical Stimulation Transcutaneous electrical nerve stimulation (TENS) Percutaneous electrical nerve stimulation (PENS) Acetaminofen (NSAID) tramadol

15 A namnesa nyeri secara sistematik dan teratur B erpikiran positif (percaya) terhadap keluhan pasien atau keluarga C arilah metode kontrol nyeri yang nyaman untuk pasien dan keluarga D ilakukan intervensi yang tepat waktunya, logis dan terkoordinasi E dukasi pasien dan keluarga untuk mengatasi nyeri sekuat mungkin

16 Analgesics Non-opioid analgesics (non-opioids): paracetamol, acetylsalicylic acid, metamizole* and nonsteroidal anti-inflammatory drugs (NSAIDs). Opioid analgesics (opioids): weak opioids (codeine, dihydrocodeine, tramadol ) and strong opioids (i.e., morphine). Co-analgesics : a diverse group of drugs, with primary indications for conditions other than pain, with analgesic properties relevant to some conditions. Commonly used adjuvant analgesics include antiepileptic drugs (AEDs), tricyclic antidepressants (TCAs) and local anaesthetics (LAs). Papaver somniferum


18 DiagnosisDrug Treatment Acute and chronic pain NSAIDS, Opioids (al tramadol), Paracetamol Myofascial pain dysfunction Analgesics, tricyclics, centrally-acting muscle relaxants, glucocorticoids Neuropathic pain, neuralgias Carbamazepine, phenytoin, baclofen, tricyclics, gabapentin, others?


20 Acetaminophen May inhibit COX selectively in central nervous system Only weak inhibitor of peripheral COX (peroxide effects?) Inhibits effects of substance P in CNS? Inhibits effects of glutamate in CNS?

21 Paracetamol 1. Paracetamol is an effective analgesic for acute pain (Level I*). 2. Paracetamol is an effective adjunct to opioids (Level I). 3. NSAIDs given in addition to paracetamol improve analgesia (Level I). 4. IV paracetamol is an effective analgesic after surgery (Level II), is as effective as ketorolac (Level II) and equivalent to morphine after dental surgery with better tolerance (Level II).

22 Dua mekanisme kerja yang saling melengkapi: 1.Kerja di opioid: - Agonis reseptor µ - Metabolit aktif (O-desmethyl-tramadol/M1) 2.Kerja di monoaminergic: Menghambat re-uptake serotonin/noradrenalin Mekanisme Kerja Tramadol

23 Serotonin/Noradrenalin µ-Receptor Menuju Otak Descending pathway Neuron dari saluran spinothalamic Transmiter nyeri Rangsang Nyeri Spinal neuron Enkephalin 22 -Receptor Tramadol Mekanisme Kerja Tramadol


25 Choose drugs based on: – mechanism of pain – safety and pharmacology of aging – match pain severity with drug potency – use combined drug and non-drug strategies Use adequate dose; appropriate route Anticipate, prevent and manage side effects

26 Rationale for a fixed-dose combination analgesic Enhanced analgesia Reduced doses of components - fewer side effects Rapid onset of action and lasting duration Broad spectrum of efficacy in terms of indications and pain intensity Higher patient compliance and ease of administration

27 Fixed drug combinations ( ZALDIAR) Fixed combinations are appropriate for on-demand treatment typically used in acute pain conditions and situations of non-stable pain or intermittent pain in chronic conditions. A fixed analgesic combination simplifies drug delivery without the need for complicated dose-escalating regimens and, therefore, improves compliance. Free drug combinations Free drug combinations are particularly appropriate for the management of stable chronic pain syndromes. The main advantage of free drug combinations is that they allow the dose regimen to be tailored to individual requirements. On the other hand, this may be time-consuming because it involves a gradual and dose-escalating strategy.

28 Kombinasi NSAID Kombinasi 2 NSAID:  Tidak dianjurkan  Efek samping meningkat  Tidak menambah efikasi Kombinasi NSAID dan Analgetik (paracetamol) Masih dapat dipertanggungjawabkan Kombinasi NSAID dengan Pelindung Lambung:  Ditujukan untuk sedikit mengatasi masalah efek samping terhadap lambung.  Dapat diberikan bersama golongan PPI, Misoprostol


30  Komposisi: 37.5 mg Tramadol plus 325 mg Taracetamol  Indikasi: Mengurangi nyeri sedang sampai berat  Sediaan: Tablet salut film  Kemasan: Box isi 10 tablet Harga 1 box : Rp 65.000 Harga 1 tablet Rp 6.500

31 INDIKASI ZALDIAR Nyeri Pasca Operasi Nyeri Osteoarthritis Tambahan pengobatan pada OA/RA yang telah diberi NSAID/COX-2 Rehabilitasi pasca cedera olahraga Trauma karena kecelakaan Bedah minor Low-back pain Nyeri sedang sampai berat seperti :

32  Dosis ZALDIAR fleksibel tergantung dari intensitas nyeri.  Untuk nyeri yang berat dosis awal bisa 2 tablet kemudian diberikan setiap 6 jam  Rata-rata dosis per hari 3-4 tablet  Maksimal 8 tablet per hari (Sama dengan 300 mg tramadol/2600 mg parasetamol) Dosis Untuk Dewasa (>12 Tahun)

33 ZALDIAR: Onset cepat durasi lama Pain relief probabilities Kerja analgesik yang saling melengkapi: Onset cepat dari parasetamol dikombinasi dengan durasi lama dari tramadol

34 Perhatian pada kelompok pasien berikut : ZALDIAR ® jangan diberikan pada: Anak-anak <12 tahun Selama hamil Selama menyusui Kategori ZALDIAR C

35 Kontraindikasi  Hipersensitif terhadap tramadol dan parasetamol  Acute intoxication alkohol, hypnotic, analgesik sentral, opioids atau obat psychotropic  Pemberian bersamaan dengan MAO inhibitor or within two weeks of withdrawal  Gangguan fungsi hati berat  Epilepsi yang tidak sedang dalam pengobatan

36 Peringatan  Dosis maksimal 8 tablet per hari  No concurrent use of any other products containing paracetamol or tramadol  Tidak direkomendasikan pada pasien dengan gangguan ginjal (creatinin clearance <10ml/mm)  Jangan diberikan pada pasien dengan gangguan hati berat  Tidak direkomendasikan pada pasien dengan gangguan pernafasan berat

37 Interaksi Kontra indikasi / tidak direkomendasikan digunakan bersamaan dengan: MAO inhibitors, Alcohol, Carbamazepine, Opioid agonists- antagonists


39 Nyeri setelah bedah mulut (gigi) Tujuan: Membandingkan efikasi dan keamanan dari tramadol/parasetamol (ZALDIAR) dengan tramadol atau parasetamol monoterapi Dosis: Tramadol 75 mg/parasetamol 650 mg 75 mg tramadol 650 mg parasetamol 400 mg ibuprofen Plasebo Medve RA et al. Anesthesi Prog, 2001

40 Desain penelitian: 1200 pasien dengan nyeri sedang sampai berat setelah bedah (cabut) gigi geraham paling belakang (geraham bungsu) yang di random menjadi 3, double blind, paralel group, studi dosis tunggal yang diobservasi selama 8 jam. Tiga pusat penelitian terdiri dari 400 pasien; yang terdistribusi merata dalam pengobatan Medve RA et al. Anesth Prog, 2001

41 *P .0001 vs Tramadol/paracetamol; † P =.0004 vs Tramadol/paracetamol; ‡ P .0001 vs all active treatments Hasil penelitian: efikasi TOTPAR 8 = Total pengurangan nyeri dalam 8 jam SPID = Jumlah perbedaan intensitas nyeri dalam 8 jam

42 Kesimpulan penelitian ZALDIAR pada pasien bedah gigi  Pengurangan / penurunan intensitas nyeri dengan ZALDIAR lebih superior dibanding tramadol atau parasetamol sendiri atau plasebo  Mula kerja ZALDIAR lebih cepat dan durasi kerja lebih lama dibanding tramadol atau parasetamol sendiri.  Masing-masing komponen dari ZALDIAR berkontribusi terhadap efikasi analgesik  ZALDIAR adalah analgesik kuat dengan onset cepat, durasi panjang yang efektif dalam pengobatan nyeri akut

43 Efek samping setelah pemberian ZALDIAR (  5%) Tramadol/ paracetamol (n=240) Tramadol (n=238) Paracetamol (n=240) Ibuprofen (n=240) Placebo (n=239) Nausea (mual) 56 (23%)56 (24%)22 (9%)23 (10%)38 (16%) Vomiting (muntah) 51 (21%)49 (21%)17 (7%)16 (7%)23 (10%) Dizzines (pusing) 11 (5%)12 (5%)10 (4%) 7 (3%)9 (4%)

44 Hasil penelitian: onset (mula kerja)

45 Hasil penelitian: durasi kerja

46 Pain: A conceptual approach to treatment (Biopsycosocial approach) Pain Behaviors Suffering Pain Perception Nociception Local block NSAIDs (Movicox ® ) Surgery Physical modalities Opioid Adjuvants NSAIDs? Acetaminophene Neural augmentation Ablative surgery Anti-depressants / psychotropics Relaxation Spiritual Cognitive therapies Functional restoration 1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3. Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.


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