More than 90% of people experience headache atsome time dur- ing their ives.' In an international survey of people seeking pri- ‘mary care, 22% reported experiencing pain for atleast 6 months during che preceding year, with 45% reporting headache? Many Iheadache sufferers self-trea with nonprescription remedies rather ‘than seck medical attention les estimated that one-third of non ‘prescription analgesic use s for headache. Migraine headache is significant cause of absenteeism and lost productivity in the ‘workplace, and affects relationships with family and fiiends.™* ‘Nearly half of patents using nonprescription pain relievers ddo not read the labeling on the container, and 43% of people surveyed were unaware ofthe risks associated with taking these agents with prescription medications." Clearly, an opportunity 10 improve medication use exists among patients self-rating, for various pain syndromes, Headaches are generally clasified as primary or secondary." Primary headaches (approximately 90% of headaches) are not associated with an underlying illness, Examples include episodic and chronic tension-type headaches, migraine headache with, and without aura, cluster headaches, and medication-overuse Ineadaches. Secondaty headaches are symptoms of an underlying, condition such as head trauma, stoke, substance abuse or with~ drawal, bacterial and viral diseases, and disorders of craniofacial This chapter focuses on the most common headaches that are amenable co self-reatment: tension-type, diagnosed migraine, and sinus headaches. Nonprescription analgesies are useful in treating headache, either as monotherapy or a adjuncts to non ‘pharmacologic or prescription therapy. Throughout this chapter, the abbreviation NSAID will be used to denote the class ofnon~ salicylate nonsteroidal anti-inflammatory agents (ibuprofen and. naproxen), ‘Tension-type headaches, aso called stress headaches, can be episodic or chronic. More than 75% ofthe U.S. population will ‘experience tension-type headaches at some time, with the I-year prevalence being 38%.'" Almost half of patients with tension- type headache report reduced effectiveness at work caused by. headache, with about 10% to 12% reporting absenteeism because ‘of head pain. Patients with chronic tension-type headaches have ‘more absentecism, missing about 18 more days per year than people with episodic headache." ‘The prevalence of migraine headache in the United Staesis about 18% for women and 6% for men.’ Onset usually begins in the first three decades of life, with greatest prevalence a around, age 40 years. Among children, boys and girs are affected equally, CHAPTER Headache Tami L. Remington but atacks usually disappear in boys after puberty.* Migraine ‘withoue aura occurs almost rwice as frequently as migraine with aura, and many individuals may have both types of headaches. Up to 70% of patients with migniine have family histories of ‘migraine, suggesting thac this disease is influenced by heredity. ‘The impact of migraine headache is substantial, Direct costs for medical services, taken from 1994 utilization data, were esti- ‘mated at $1 Billion in the United States. A greater burden comes in the form of lost productivity and wages, with migraine cost- ing $13 billion for American employers. Migraine headaches affect health-related quality off in a manner similar to that of depression, despite the episodic nature ofthe headaches? Headache isa frequently reported symptom i patients with acute sinusitis, These patients will also experience other sinus symptoms such as toothache in the upper teeth, ficial pain, nas stufliness, and nasal discharge. The actual frequency of occur- rence of sinus headache is low, and up t0 90% of patients who believe they have sinus headache may actually be experiencing ‘migraine headache” Pathophysiology of Headache “Tension-type headahes often manifest in response to srs, anxiety, depression, emotional confics, and other stimuli fis key that tension-type and migriine headache share pathophysiologic fea- ‘ures, making them more similar than distinct. ** “Migraine headaches probably aise from a complex: interaction ‘of neuronal and vascular factors, Seres, fatigue, ovenleeping, fasting or missing a meal, vasoactive substances in food, caf feine, alcohol, menses, and changes in barometric pressure and altitude may trigger migraine. Medications (reserpine, nitrates, ‘oral contraceptives, and postmenopausal hormones) can also trigger migraine. Although sill debated, personality features of ‘migraine sufferer include perfectionism, rigdty, and compul- sivenes. Menstrual migraines appear at the menstrual sage of the ovarian cycle and occur in les than 10% of women. Most women ‘with migraines experience attacks in the premenstrual period and, forsome women, migraine headaches recur at specific times before, after, oF during the menstrual cycle. “Most investigation into the pathophysiology of headache has centered on mignsine headache. The best evidence suggests that ‘migraine occurs through dysfunction of the erigeminovascular system, Neuronal depolarization that spreads slowly across the cerebral cortex is observed during the aura phase. Magnesium deficiency may contribute to this state. Simalation (by an axon66 SECTION 11 _ Pain and Fever Disorders reflex) of trigeminal sensory fibers in the large cerebral and dural vessck causes neuropeptide release with concomitant neurogenic inflammation, vasodilation, and platelet and mas cell activation daring the headache phase Sinus headache occurs when infection or blockage of the paranasil sinuses causes inflammation or distention of the sen= sitive sinus walls (sce Chapter 11). Most patients who believe they have sinus headache may actully have migraine headache.” athophysiologic mechanisms at work during migniine headache «an produce prominent sinus congestion, “Although a number of medications can cause headache asa side effect, issues discussed here relate to overuse (rebound) and ‘withdrawal of agents used for analgesia. Medication-overuse hheadaches area challenging area for clinicians. Agents asoci- ated with these headaches are acetaminophen, aspirin, caf- fine, triptans, opioids, butalbital, and ergotamine formations" Medication-overuse headaches are usually asociated with fre- quent use (more than twice weekly) for 3 months or longer, and occur within hours of stopping the agent; re-administration provides relief, Symptomatology shifts from the baseline headache type to a nearly continuous headache, particularly noticeable on awakening. This continuous headache may be punctuated by periodic headaches of the baseline type: some patients note an increased frequency of their baseline head- ache type, When medication-overuse headache is suspected, use of offending agents) should be tapered and subsequently climinated, Most often, this should be done with medical super- vision, because use of prescription therapies may be needed to combat the increased headaches that temporarily ensue during the days to weeks of the withdrawal period." Clinical Presentation of Headache Headaches can be differentiated by their signs and sympcoms (Table 5-1) Shivering or cold temperatures may increase pain from tension-type headaches. Chronic tension-type headaches ‘occurring at least 15 days per month for atleast 6 months, may bea manifesation of psychologic conflict, depression, or anxiety, and may be associated with sleep disturbances, shormess of breath, constipation, weightlos, fatigue, decreased sexual drive, palpita~ tions, and menstrual changes. The severity of pain associated with tension-type headaches s variable; some headaches are so mild 2s 10 not require treatment, whereas others are sufficiently severe to be dialing.” Migraine headaches are casified as migraine with or with= ‘out aura. Aura manifests asa series of neurologic symptoms shimmering ot ashing ateas or bind spot in dhe visual fel, di Ficuly speaking, visual and auditory hallucinations, and (usally) ‘one-sided muscle weakness, These symptoms may lat for up t0 [30 minutes, and the ehrobbing headache pain that follows may. last from several hours to 2 days. Migraines without aura begin, immediately with the throbbing headache pain. Both forms of ‘migniine ae offen asociated with nausea, vomiting, photopho- bia, phonophobia, sinus symptoms, tinnitus, light-headedness, vertigo, and irritability, and are aggravated by routine physi- cal activity. A migraine attack may have a prodrome of a bust ‘of energy or fiigue, extreme hunger, and nervousness. Migraine ppain tends to be much more severe than that associated with tension-type headaches, with 80% of migraineurs reporting their pain as severe." Sinus headache is usually localized to facial areas over the simses and is difficule to diferentate from migraine without aura, ‘The pain quality i typically dull and pressute-like. Stooping or ‘lowing the nose often intensifies ehe pain, but sinus headache is not accompanied by nausea, vomiting, of visual disturbances Persistent sins pain and/or discharge suggests possible infection and require refer for medical evaluation. Treatment of Headache Treatment Goals ‘The goals of treating headache are to (1) alleviate acute pain, {Q) rescore normal functioning, (3) prevent relapse, and (4) min mize side efects. For chronic headache, an additional gol isto reduce the frequency of headaches. General Treatment Approach Most patients with episodic headaches respond adequately to self treatment with nonpharmacologic interventions, non prescription medications, or both. Some patients with episodic Iheadaches and most with chronic headaches are candidates for prescription treatments. However, these patients will ofen we nonprescription therapies adjunctively Tee Tension-Type Headache Migraine Headache Sinus Headache Location Bilateral Usually unilateral Face, forehead, or periorbital area ‘Over the top of head, extending o base of skull Nature Varies fom diffuse ache to tight, pressing, Throbbing Pressure behind eyes or face ‘constricting pain May be preceded by an aura Dull lateral pain Worse inthe morning Onset Gradual sudden Simultaneous wit sinus symptoms, including purulent nasal decharge Duration Minutes to days Hours to 2 days Days (resolves with sinus symptoms) Source: References 6 and 7Episodic tension-type headaches often respond well © non- prescription analgesic, including acetaminophen, NSAIDs, and, salicylates, especially when taken as soon as the headache starts. If ‘nonprescription analgesics are use to treat chronic headache, fe- {quency of use should be limited to prevent medication-overuse headache. Chronic tension-type headaches usually benefit from physical cherapy and relaxation exercises in addition to non= [prescription of prescription medication, Figure 5-1 outlines the seléreatment of headaches and lists exclusions for self-ereatment, ‘A medical diagnosis of migraine headache is required before selftreatment can be recommended. Taking an NSAID oF salicylate atthe onset of symptoms can abore mild or moderate ‘migraine headache, Once a migraine has evolved, analgesics are less effective. Patients with migraines who can predict the occur rence ofthe headache (¢g., during menstruation) should take an analgesic (usually an NSAID) before the event known to trigger the headache, as wells throughout the duration of the event, For patients with coexisting tension and migraine headaches, treatment of the initiating headache type can abort the mixed, headache problem. Itis not always necessary co trea both types For patients with sinus headache, decongestants (e, pseudoephedrine) are often usefull in facilitating drainage of Patent with complaint cof headache ¥ ‘Assoas patient & the pain. Obtain ‘medical & medication history, ‘Ask about attempted treatments ¥ Headache CHAPTER 5 67 the sinuses (ee Chapter 11). Concomitant use of deconges- tants and nonprescription analgesics can relieve the pain of sinus headache. Nonpharmacologic Therapy Chronic tension-type headaches often respond to relaxation exer- ‘ses and physical therapy tha emphasizes stretching and strength- «ning of head and neck muscles. General treatment measures fOr ‘migaine include maintaining regular sleeping and eating sched- ule, and practicing methods for coping with stress. Some patients ‘with migraines benefit ffom use of ice (ice bags or cold packs) combined with pressure applied to the forehead or temple ateas oreduce pain ascociated with acute migraine attacks, Nutritional serstegies are intended to prevent migraine and are based on (1) dietary restriction of foods that contain triggers, (2) avoidance of hunger and low blood ghicose (atrig- ger of migraine), and (3) magnesium supplementation, Advocates Of nutritional cherapy recommend avoiding foods with vaso~ active substances sich as nitrites, cyramine (found in ted wine and aged cheese), phenylalanine found in the artical sweet- ener aspartame), monosodium glutamate (often found in Asian food), caffeine (in coffee, ea, cola beverages, and chocolate), Exclusions for selftreatment (Gee box)? Yes ‘Medical referral T No ¥ Analgesic use for headache >3 ays per week? T -Yes—>| persists Decrease analgesic use over afew days; medical referalf headache No Diagnosed migraine or symptoms typical of sinus or L_-No—m Mecical ceferal tension-type headache? Yes ¥ Recommend appropriate ‘nonpharmacologic & pharmacologic therapy 1 ‘Go to next page ID, nonsteroidal antiinflammatory drug; OTC, over-the-counter. continued on next page) eee Key: CHF, congestive heart failure; Gl, gestrointesnl: HBP, high blood pressure:68, SECTION 11 _ Pain and Fever Disorders ‘Asta casa polps conic tecuent Gl los, ov, CGaguation isons or “void aheyates & NEADS Srecoogulant therapy, HBP, CHF, iiey eas, or apn allan No “iz years ofage? Avoid naproxen l ° Frat algae ammpions of 515 years of age? LYes—m) wisiiness ae present” | —"— Fortensionype headache, fevonmend seetominoshen, }«—__________] NSAID or sate as appropriate Formignine, recommend NSAID says as appropriate Follow up based on headache frequen orsevery ¥ ¥ Severe headache ‘Chronic headache pode headache ¥ ¥ Follow up within 10 dys Follow up ater 46 weeks Follow up ater 612 woaks ‘Continue intermittent use ressure; NSAID, nonsteroidal anti and theobromines (in chocolate). Any food allergen ean also be a erigger.” Pharmacologic Therapy Available nonprescription analgesics for management of headache include acetaminophen, NSAIDs (ibuprofen and naproxen), and salicylates (aspirin, magnesium salicylate, and sodium salicylate). Although these agents are available without a prescription, they are not benign; selection of an analgesic should be based wescrwiera eno] ‘goaaese [erp] Sines pee BPE Cortinec Salecare of headache. Key: CHF, congestive hear fare Gl gasvintentival HP, high blood flammatory drug; OTC, over-the-counter. ‘on a care review of a patient's medical and medication histo- ries, Medical management of nausea accompanying. migraine headache may ako be indicated to improve symptomatic relief and ficiitate medication delivery by the oral route ‘Acetaminophen Acetaminophen san effective analgesic and antipyretic, but it does ‘not posses antiinflammatory activity. Acetaminophen produces analgesia through a central inhibition of postagandin synthesis,Acetaminophen is apidly absorbed from the gastrointestinal (GD traceand extensively metabolized in the liver to inactive ghi- ‘curonie and safc acid conjugates. In addition, acetaminophen, ‘is metabolized to a hepatotoxic intermediate metabolite by the ‘cytochrome P450 enzyme system. This ineermediate metabolite is detoxified by glutathione. Rectal bioavailability of acetamino~ phen is approximately 50% to 60% of that achieved with oral administration, Onset of analgesie activity of acetaminophen i about 30 minates after oral administration, Duration of activ= ity is about 4 hours and is extended to 6 to 8 hours by using an ‘extended-release formulation, ‘Acetaminophen is effective in relieving mild-to-moderate pain of nonvisceral origin, Randomized, double-blind, placebo- ‘controlled studies have documented superiority ofacetaminophen. 1000 mg over placebo in patents with migraine and tension-«ype Iheadache.!5" Recommended pediatric and adule dosages of acetamsino- phen are provided in Tables 5-2 and 5-3. Table 5-4 lists select trade-name products. Acetaminophen is available for administration in various ora and rectal dosage forms, Acetaminophen oral capsules contain, tasceless granules that can be emptied onto a spoon containing a small amount of drink or soft food, Patients and parents should not add contents of che capsules to a glass of liquid, because lange numbers of granules may adhere eo the side of the glas. Mixing with a hot beverage can result in a biter taste. Acetaminophen is potentially hepatotoxic in dases exceed ing 4 g/day, especially with chronic ws. Patients should be eat toned against exceeding this dose limit. More conservative dosing (ie. 2 g/day oF les) or avoidance may be warranted in patients at increased risk for acetaminophen-induced hepatotoxicity, includ- ing those with concurrent use of other potentially hepacoroxic «drugs, poor nutritional intake, or ingestion of tree or more alco- holie drinks per day." ‘Acetaminophen poisoning isa major reason for contacting, poison control centers and the leading cause of acute liver fil- lure in the United States." Hepatotoxicity from acetamino~ ‘phen is probably dose-related and i uncommon at recommended closes." In a prospective study, 83% of patients presenting with, acetaminophen hepatotoxicity had taken more than 4 g/day." Unintended chronic overdose comprises about half ofthe cases ‘of acetaminophen-induced acute liver failure, Contributing, factors include repeated dosing in excess of package label- ing, use of more than one product containing acetaminophen, and alcohol ingestion,” In an attempt to reduce the occurrence fof accidental overdose, the Food and Drug Administration (FDA) recommended labeling changes for prescription and nonprescription products to make acetaminophen content ‘more evident.” In che United Kingdom, limiting package size 10 16 tablets has reduced deaths attributable to acetaminophen overdose.” Ichas been proposed that malnutrition and aleohol intake are risk factors for acetaminophen-induced hepatic injury, but this proposals refuted owing tothe paucity of clinical evidence supporting the relationships.""2" Of ineerest to note, neatly two-thirds of subjects in one study who reported daily alcohol ‘consumption also reported cy use or abuse of acetaminophen. Despite these usage pattems, none of them developed hepato toxicity 2» Early symptoms of acetaminophen intoxication can include nausea, vomiting, drowsiness, confusion, and abdominal pa ‘but these symptoms may be absent, belying the potential gravity ‘of the exposure, Serious clinieal manifestations of hepatotoxicity Headache CHAPTER 5 69 Weight Agent er Age (mg) Acetaminophen 10-15 &-11lb 40" 12417 80: 18-2315 120° 24-351 160 36-47 1b 240 48-5915 320 eo-711b 400 72-951 480 26lb 650 Iouprofent 75 1217 50° 18-231 75° 24-3515 100 35-471 150 48-591 200 -71lb 250 72-951 300 295 1b 200-400mg (maximum 1200 mday) Naproxen sodium <12,years Not recom- ‘mended >i2years 220-4409, ‘then 220 mg every 8- hous (raximum 660 mg/day) Aspirnt 1015 <2 As directed by heath care provider 24-3510 162° 36-47 lb 243° 48-591 324 -71lo 405 72-9510 486 26lb 6a “Individual doses may be repeated every 4-6 hours as needed, ot to exceed five doses in 28 hours * Individual doses may be repeated every 6-8 hours as needed, not 1 exceed four doses in 24 hours. “Data from The Harriet Lane Handbook: A Manual for Pediatric House Ofcers. 17th ed, Philadelphia: Elsevier Mosby: 2005, begin 2 to 4 days afer acute ingestion of acetaminophen and include increased plasma aspartate aminotransferase and alanine aminoransferase (ALT), increased plasma bilirubin with jaun- dice, prolonged prothrombin time, and obrundation, in the majority of cases, hepatic damage is reversible over a period of ‘weeks or months," but fatal hepatic necrosis ean occu.70 SECTION 11 Pain and Fever Disorders Usual Adult Dosage Agent Dosage Forms (Maximum Daily Dosage) ‘Acetaminophen Immediate-rlease, extended-clease ofervescent, disintegrating, 325-1000 mg every 44 hours rapid-elease, and chewable tablets; capsules; iquid drops; els; (4000) suspension; suppositories louprofen Immeciateelease and chewable tablets; capsules; suspension; liquid 200-800 mg every 4-6 hours drops (1200 mg) Naproxen sodium Tablets 220 mg every 8-12 hours (660 ma) Aspicin Immediate-release, buffered, enterc-coated, fim-coated, effervescent, 650-1000 mg every 4-6 hours and chewable tablets; suppositories; chewing gum (4000 mg) Magnesium salicylate Tablets £650 mg every 4 hours or 1000 mg ‘every hours (4000 ma) Because ofthe potential seriousness of acetaminophen over dose, all cases should be referred to a poison control center or emergency department. In addition to supportive eae, activated charcoal (or other method of gut decontamination) is used to reduce the absorption of acetaminophen in patients who present shorty after acute overdose. When acetaminophen serum levels {elated to time since ingestion) exceed those known to cause hepatic injury, administration of acetyleysteine is warranted. Prompt administration is important given that aceryleysteine’s effectiveness is reduced when administration is delayed beyond Shoursater acute ingestion, For patients with chronic ingestions of greater than 4 w/day, administration of aceeylysteine is indi- cated until liver toxicity is ruled out by assessing liver enzymes and liver function, Acetaminophen Trade Name Content Pediatric Formulations Children’s Tylenol Mekaway Tablets 80mg FeverAl infants’ Suppositories 80mg FeverAll Chen's Suppositories 160mg FeverAll Junior Strength Suppositories 325mg Je Tylenol Meltaway Tablets 160mg ElnSure Childeen’s Oral Solution 160 mg/S mL Infants’ Tylenol Drops 80mg/0.8 mL. ‘Adult Formulations Tylenol Ahr Pain Caplets 650mg Tylenol Baa Svrength CapletsCool 500mg ‘Caplets/Rapid Release Geleaps! Go Tabs/Ez Tabs Tylenol Rapid Bast Liqus 1500 mg/'15 mL. Tylenol Regular Strength Tablets 325mg Asymptomatic elevations in seam ALT have been reported: in otherwise healthy individuals taking acetaminophen 4 g/day. Ima prospective study, 39% of patients experienced ALT eleva~ tons greater than three times the upper limit of normal. These elevations generally appeared in the ise week of use, with some ‘resolution despite continued dosing. The clinical significance of this observation i uncer Patients with ghicose-6-phosphate dehydrogenase defi- ciency should ao use caution when medicating with acetamin= ‘ophen, Use of acetaminophen s contraindicated in patients who are hypersensitive to the medication. Clinically imporeant drug interactions of acetaminophen are listed in Table 5-5. For patients taking warfarin, acetaminophen, is considered the analgesic of choice; however, it has been 2ss0- ciated with increases in international normalized ratio (INR). Regular acetaminophen use should be discouraged in patients on ‘warfirin, Patients who require higher scheduled doses (et, hose ‘with osteoarthritis) should have their INR. monitored and war- ‘arin adjusted as acetaminophen doses ate titrated, Nonsteroidal Anti-Inflammatory Drugs NSAIDs relieve pain chrough peripheral inhibition of eyclo- ‘oxygenase (COX) and subsequent inhibition of prostaglandin synthesis, All nonprescription NSAIDs are rapidly absorbed from the Gl eract with consistently high bioavailability. They are exten sively metabolized to inactive compounds in the liver, mainly by _lucuronidation. Elimination occurs primarily through the kid- nneys. Naproxen sodium and ibuprofen have onsets of activity of bout 30 minutes. Analgesia from naproxen sodium lists pt 12 hours, whereas ibuprofen lst about 6 to 8 hours ‘The EDA-approved uses for nonprescription NSAIDs include reducing fever and relieving minor pain associated with, headache, the common cold, toothache, muscle ache, back- ache, arthritis, and menstrual cramps. NSAIDs have analgesic, antipyretic, and anti-inflammatory activity, and are useful in ‘managing mild-to-moderate pain of nonvisceral origin. Two agents (propionic acid derivatives) are available for nonpre= scription use: ibuprofen (1984) and naproxen sodium (1994). ‘Tables 5-2, 5-3, and 5-6 lise pediatric and adult doses and selected trade-name products of nonprescription NSAIDs. A.ly Imp Headache CHAPTER 5 n Analgesic! Antipyretic Drug Potential Interaction Management/Preventive Measures ‘Acetaminophen Alcohol Increased risk of hepatotoxicity Avoid concurent use if possible; mini- ‘mize alcohol intake when using ‘acetaminophen. ‘Acetaminophen wararin Increased sk of bleeding elevations in INR) Limit acetaminophen to eccasional use; ‘monitor INR for several weeks when ‘cetaminophen 2-8 g dally is added or iscontinued in patients on warfarin, Aspitin Valproic acid Displacement from protein-binding ‘Avoid concurent use; use naproxen ‘tes and inhibition of valproic sid instead of aspen (no interaction), ‘metabolism Aspirin NSAIDs, including Increased risk of gastroduodenal ulcers Avoid concurrent use i possible; con- COX2inhibitors and bleeding ‘sider use of gastroprotectve agents (eg, PP) Ibuprofen Aspirin Decreased antiplatelet effect of aspirin Aspirin shouldbe taken at least 30 min ‘ues before or 8 hours after ibuprofen, Use acetaminophen (or other analgesic) instead of ouproten Ibuprofen Phenytoin Displacement from protein-binding sites Monitor free phenytoin levels; adjust ose as indicates, NSAIDs (severad Bisphosphonates Increased risk of GI or esophageal Use caution with concomitant use. Ulceration NSAIDS (several Digoxin Inhibit renal clearance of digoxin Monitor digosn levels; adjust dose as indicated Sslcyates and ‘Antihypertensive Antihypertensive effect inhibited: possi- Monitor blood pressure, cardiac function [NSAIDs (several) agents, beta- ble hyperkalemia with potasium- ‘and potassium levels. blockers, ACE sparing urtics and ACE inhibitors inhibitors, vasodilator, siurtios Salcylates and NSAIDs Anticoagulants Sslcystes and NSAIDs Alcohol Salcyates and Methotrexate [NSAIDs (several) Salcylates (moderate: Sulfonlureas torhigh doses) Increased risk of bleeding, especially GI Increased risk of GI bleeding Decreased methotrexate clearance Increased risk of hypoglycemia ‘Avoid concurent use, if possible; lowest risk wth salsalate and choline magne: sium wsaiyate, ‘Avoid concurent use, i possible; min- ‘mize alcohol intake when using slcy- lates and NSAIDs ‘Avoid salcyates and NSAIDs with high- ‘dose methotrexate therapy: monitor levels with concurrent treatment. ‘Avoid concurtent use, if possible; monitor ‘blood glucose levels when changing salicylate dose. Key: ACE, angiotensin-converting enzyme; COX, cyclooxygenase; Gl, gastrointestinal INR, intemational normalized ratio; NSAID, nonsteroidal ant-iflammatory drug; PP, protein pump inhibitor. dose-effect relationship has been demonstrated for ibuprofen analgesia in the range of 100 to 400 mg, ‘Overdoses of NSAIDs usually produce minimal symptoms ‘of tonicity and are rarely fatal. Ina prospective study of 329 cases ‘of ibuprofen overdose, 43% of ibuprofen-overdose patents were asymptomatic, Among. patients with symptoms, Gl and central ‘nervous system (CNS) symptoms were most common (in 42% and 30% of patients, respectively) and included nausea, vomiting, abdominal pan, lethargy, stupor, coma, nystagmus, dizziness and light-headedness. Hypotension, bradycardia, tachycardia, dysp- nea, and painful breathing were aso reported.” The most frequent adverse effects of NSAIDs involve he GL tract and include dyspepsia, heartburn, nausea, anorexia, and epi- gastric pain, even among children using pediatric formulations ‘These agents produce les GI upset and bleeding than aspirin. NSAIDs may be taken with food, milk, oF antacids i they upset the stomach, Tablets should be taken with a fll glas of water, suspensions should be shaken thoroughly, and enterie-coated72 SECTION II Pain and Fever Disorders eae Trade Name Primary Ingredients Pediatric Formulations of Ibuprofen Products CCildren’s Adil Suspension lbuprofen 100:mg/S mL CCildren’s Advil Chewable Tablets Ibuprofen 50 mg Junior Strength Adil Chewable Ibuprofen 100mg ‘and Swallow Tablets ‘Children’s Motrin Suspension Infants Motrin Concentrated Orops Junior Strength Motrin Tablets! Caplets Tbuproten 100 mg/5 mL. Ibuprofen $0 mg/1.25 mi. Ibuprofen 100mg Adult Formulations of Ibuprofen Products ‘Advil Migeaine Capsules lbuprofen 200mg ‘Advil Tablets/Coplets/Gel Caplets Ibuprofen 200 mg Midol Cramps & Body Aches luprofen 200 mg Tablets Mottin 8 Tablets/Caplets Ibuprofen 200mg Naproxen Products Aleve Tablets/Caplet/Liquid Gels/Smooth Gels Midol Extended Relief Caplets Naproxen sodium 220 mg Naproxen sodium 220 mg or sustained-release preparations should be neither crushed nor chewed. Other advene effects include dizziness, fatigue, headache, of nervousness. Rashes or itching may occur in some patients, and some cases of photosensitivity have been reported. Fluid retention can occur and, in some cass, edema develops. At normal nonprescription doses, these effects are usually rare, Gl ulceration, perforation, and bleeding are uncommon but serious complications of NSAID use. Risk factors include age colder than 60 years, prior ulcer disease or GI bleeding, concurrent tse of anticoagulants (including aspirin), higher dose or longer duration of teatment, and moderate use of alcohol, Package hbel- ing for NSAIDs inclide wamings about stomach bleeding, NSAIDs are asociated with increased risk for myocardial infarction, heart failure, hypertension, and stroke. The mech- anism by which they confer this risk is mot clear, but may be related t0 increased thromboxane A2 activity and suppressed vascular prostacyclin synthesis, resulting in vasoconstriction and platelet aggregation, On ehe bass of the results from meta- analyses of randomized tials, it appears that the cardiovascular risk of nonselective NSAIDs is dose- and duration-dependent. Inaadition, there are differences in rsk between individual non- selective NSAIDs: ibuprofen has been associated with a signi- cant increase in cardiovascular risk, whereas naproxen has not. ‘The American Heart Association recommends chat patients with or at high risk for cardiovascular disease (hyperlipidemia, hypertension, diabetes, or other macrovascular disease) should avoid NSAIDs, Even patients a low rsk should use these agents cautiously, atthe lowest dose and shortest duration needed to control symptoms, Naproxen was identified asa preferred drug because it appears to be safer than ibuprofen,” FDA has empha- sized that patients using NSAIDs for longer than 10 days should do so only with medical supervision.» Clinically important drug-drug interactions of NSAIDs are listed in Table 5-5, Ibuprofen inereases bleeding time by reversibly inhibiting platelet aggregation. Patients taking aspirin for cardiovascular prophylaxis should take it at lease an hour before or 8 hours after ibuprofen to avoid a pharmacodynamic inceraction that inhibits the antiplateler effect of aspirin, In doses ‘oF 1200 to 2400 mg/day, ibuprofen does not appear to affect the INR in patients taking warfarin, However, ibuprofen should not ‘be recommended for self-treatment in patients who are concur- rently taking anticoagulants because its antiplatelet activity could increase GI bleeding. ‘As with other nonprescription analgsies, patients who have three or more alcoholic drinks per day should be cautioned about the increased risk of adverse GI events, including stomach bleed ing, and be referred to their primary care provider regarding us. NSAIDs may decrease renal blood flow and glomerular {ilration rate asa resule of inhibition of renal prostaglandin syn thesis. Consequently, increased blood urea nitrogen and serum creatinine values ean occur, often with concomitant sodium and water retention, Advanced age, hypertension, diabetes, ach- ‘erosclerotic cardiovascular disease, anid use of diuretis appear to increase the rk of renal toxicity with ibuprofen use. Asa result, patients with a history of impaired renal function, congestive hheatt failure, oF diseases that compromise renal hemodynamics should not se medicate with NSAIDs. Salicylates Salicylates inhibit prostaglandin synthesis from arachidonic acid by inhibiting both isoforms of the enzyme cyclooxygenase (COX-1 and COX-2), The resulting decrease in prostaglandins reduces the sensitivity of pain receptors Co the initiation of pain ‘impulses at sites of inflammation and trauma, Although some evidence suggests that aspirin also produces analgesia through a ‘central mechanism, its ste of action is primarily peripheral Salicylaces are absorbed by pasive diffusion of the non~ ionized drug inthe stomach and small intestine. Factors affecting absorption include dosage form, gastric pH, gastric-emptying. time, dissolution rate, and the presence of antacids or food. [Absorption from immediate-rlease aspirin products is complete. Rectal absorption of salicylate is slow and unteliabe, as well as proportional to rectal retention time. ‘Once absorbed, aspirin s hydeolyzed in the plasma to salicylic acid in Ito 2 hours, Salicylic acids widely cistibuted to al dssues and fluid in the body inchuding the CNS, breast milk, and fetal ‘sue. Protein bindings concentration-dependent. At concent tions lower than 100 mg/mL, approximately 90% of salicylic acid is bound to albumin, whereas at concentrations greater than +400 mg/ml approximately 75% is bound, Salicylic aidis largely, climsinated through the kidney. The pH of the urine determines ‘the amount of unchanged drug eliminated, with urinary concen= trations increasing substantially in more alkaline urine (pH ~8). Dosage-form alterations include enteric coating, buffering, and sustained release, Such formullations were developed 0 ‘change the rate of absorption and/or reduce the potential for GL toxicity. Enteric-coated aspirin is absorbed only fiom the small inestne; its absorption is markedly slowed by food, attributed to prolonged gastric-emptying time, Hypochlorhydria from acid suppressing agents (especially proton pump inhibitors) may resale in disolution of enteric-coated products in the stomach, negat- ing any potential benefit on local gastric toxicity. For patients ‘requiring rapid pain relief, enteric-coated aspirin is inappropriate ‘because ofthe delay in absorption and the time to analgesic effect.Buffered aspirin products are availble in both tablet and. effervescent forms. Although they are absorbed more rapidly than nonbutcred products, time to onset of effect is not improved appreciably. Common buffers include aluminum hydroxide; magnesium carbonate, hydroxide or oxide; calcium carbon ate; and sodium bicarbonate (in effervescent formulations). Some effervescent aspirin solutions contain large amounts of sodium and must be avoided by patients who require restricted sodium intake (e.g, patients with hypertension, heart hilure, ‘or renal filure), Sustained-release aspirin is formulated to pro long the product's duration of action by slowing dissolution and absorption. ‘The salicylate content of 377 mg of magnesium salicylate tetrabydeate is equivalent to 325 mg of sodium silicylate Salicylates are approved for treatment of symptoms of ostoo~ arthritis, sheumatoid arthritis, and other rheumnatologic diseases, and for temporary relief of minor aches and pains sociated with backache or muscle aches. They are also effective in treating, mild-to-moderate pain from musculoskeletal conditions and fever. Aspirin possesses other important uses for indications ‘unrelated to pain syndromes. Its indicated for prevention of thromboembolic events, such as myocardial infiretion and stroke, in high-risk patients, owing to is inhibitory effects on platelet faction, ‘Tables 5-2 and 5-3 list pediatric and adult dosages of non- prescription salicylates. Table 5-7 provides select salicylate prod- "ucts. Aspitin dosages in che ringe of 4 t0 6 g/day are offen needed. to produce anti-inflammatory effets. The maximuin analgesic dosage for self-medication with aspirin is 4 g/day; therefore, anti- inglammatory activity often will not occur unless the drug is used atthe high end of the acceprable dosage range. Mild salicylate intoxication (slicylism) occurs with chronic therapy that produces toxic salicylate plasma concentrations Chronic intoxication in adults generally requires aking sali cylate 90 t0 100 mg/kg/day for at least 2 days. Conditions ‘thac predispose patients to salicylate toxicity include (1) marked renal oF hepatic impairment (L.e., uremia, cirrhosis, or hep ‘Trade Name Primary Ingredient Alka Selzer Orginal Effervescent Aspirin 325 mg ‘Tablets ‘ayer Low-Dose Chewable Aspirin 81 mg ‘Aspirin Tablets St Joseph 81 mg Chewable Aspirin Aspirin 81 mg Ecotrin Adult Low Strength Tablets Aspirin 81 mg Ecotin Regular Strength Safety- Aspirin 325 mg ‘Coated Tablets xtra Strength Bayer Aspirin Aspen 500 m9 Coated Caplets and Geleaps Genuine Bayer Aspirin Tablets Aspirin 225 mg Deoar’s Pils Magnesium salicylate 377 mg "Momentum Maximum Strength Backache Relief Coated Caplets Magnesium salicylate tetvahydrate S80 mg Headache CHAPTER 5 73 titi): (2) metabolic disorders (Le., hypoxia or hypothyroidism); {@) unstable disease (ie, cardiac arthythmias, intractable epilepsy, or brite diabetes); (4) status asthmaticus; and (5) multiple comorbidities. Symptoms include headache, dizzines, tinni- tus, difficulty hearing, dimness of vision, mental confusion, Iassitude, drowsiness, sweating, thirst, hyperventilation, nau~ sea, vomiting, and occasional diarshea, These symptoms ae al reversible in response to lowering the plasma concentration to a therapeutic range. Tinnitus, eypically one of the early signs of toxicity, should not be used asa sole indicator of salicylate toxicity Acute salicylate intoxication is categorized as mild (ingestion of <150 mg/kg), moderate (ingestion of 150-300) mg/kg), oF severe {ingestion of >300 mg/kg). Symptoms are concentration= dependent and include lethargy, nausea, vomiting, dehydration, tinnitus, hemorrhage, tichypnea and pulmonary edema, convul- sions, and coma, Acid-base disturbances are prominent and range fom respiratory alkalosis to metabolic acidosis, Initially, akcylate affects the respiratory center in the medulla, producing hyperven= tiation and respiratory alkalosis. In severely intoxicated adults and Jn most salieylate-poisoned children younger than 5 years, respi- ratory alkalosis progresses rapidly to metabolic acidosis. Children are more prone than adults to develop high fever in salicylate poi- soning. Hypoglycemia resulting from increased glucose utiliza- tion may be especially serious in children. Bleeding may occur fom the GI tract or mucosal surfaces, and petechiae ate a promi- nent feature at autopsy. Emergency management of acute slieylate intoxication s irected toward preventing absorption of salieylate from the GI tract and toward supportive care. Activated charcoal should be used at home only if recommended by poison control or emer- agency department personnel. In an emengency' department set- ting, gut decontamination with gastric lavage of activated charcoal may be undertaken. Enhancing renal elimination can be accomplished through alkalinization of the urine. Dosing. recommendations for the use of activated charcoal ae included in Chapter 21 Upper Gi symptoms occur in about half of people who take aspirin. Dyspepsia, epigastric discomfort, nausea, and vomiting. have all been reported, and may be lesened by taking aspirin with food. These symptoms are not necesaily related to more serious Gl adverse evens from aspisin, Aspirinis asociated with gastritis and ulceration of the upper Gl tact. Ie produces GI mucosal damage by penetrating the pro~ fective mucous and bicarbonate layers ofthe gastric mucosa and permitting back-diffision of acid, thereby eausing cellular and vascular erosion, Two distince mechanisms cause this problem: (1) local ivtant effect resulting from the medication contacting the gastric mucosa and (2) a systemic effect from prostaglandin inhibition, Endoscopy studies reveal upper GI mucosal damage from episodic and chronic aspirin ingestion. Gastric peteciae and ero- sions occur within | to 2hoursaftera single 600 mg dose. Lower doses of 300 mg/day for 14 days also show gastric and duodenal petechiae, erosions, and endoscopic ulcers. Other data have shown that 10% of patients taking daly doses of 300) mg or less for 12 weeks have documented gastric ulcers. However, the clinical importance of these findings s uncertain because they do not necessarily correlate with sympeoms or adverse clinical outcomes. GI blood loss with aspirin is dose-dependent and has been demonstrated in patients taking only 75 mg/day, Normal subjects swith no aspirin exposure lose approximately 0.5 mL of blood per74 SECTION 11 _ Pain and Fever Disorders day in the stool. Moderate aspirin intake increases this amount to 2 c0 6 mi per day, and up co 15% of patients will lose in exces ‘of 10 ml. per day. Chronic GI bleeding of this magnitude can deplete total body iron and produce iron deficiency anemia, Patients with risk factors for upper GI bleeding should avoid self-treatment with aspirin. These risk factors include (1) history of uncomplicated o bleeding peptic leer; (2) age older than 60 years; (3) concomitant use of other NSAIDS, anti- coagulants, antiplatelet agents, bisphosphonates, selective eto~ ‘onin reuptake inhibitors, or systemic corticosteroids; (4) higher dose of aspirin; () infection with Hllobacter pylon (6) thewma- toid arthritis, (7) NSAID-related dyspepsia; and (8) concomitant use of alcohol” ‘Various aspirin formulations may have different rates of GL side effects. Enteric coating may reduce occurrence of mucosal lesions identified by endoscopy, as well ax decrease local gastric inritation." Therefore, enterc-coated aspirin isa preferred dosage form for patients requiring chronic therapy with medium-to-high doses." However, no difference among plain, enteric-coated, and btfered products has been identified for risk of major upper Gl bleeding that results in hematemesis or melena.* Endoscopic eval- ‘uation comparing buffered and nonbuffered apitin prods sug- gests similar rates of gastric damage.”* Serious aspirin intolerance is uncommon and consiss of two types: urticaria- angioedema type and bronchospastic type. These adverse effects usually occur within 3 houts of aspirin ingestion and present with urticaria, angioedema, dificulry with breathing, bronchospasm, profuse shinomrhea, and shock. The mechanism js not immunologically mediated and does not preclude use of nonacetylated salicylates Risk factors for serious aspirin intolerance include chronic urticaria (for urticaria-angioedema type) and asthma with nasal polyps (for bronchospastic sype). In patients with one of these conditions, the incidence of serious aspirin intolerance has been reported to range from 100% co 30%, Severity ofthe intolerance Js variable, ranging from minor to severe. [Nonprescription iicylates interact with several other impor- tant drugs and drug clases, Table 5-5 lists clinically important drug interactions reported forsaleyltes. Clinicians should review current drug interaction references for newly identified inter- actions when monitoring therapy in patients who are taking. high-dose salicylates, ‘Aspirin ingestion may produce positive results on fecal ‘occult blood testing; therefor, its use should be discontinued forat least 3 days before testing. Similarly, aspirin should be dis- continued 2to 7 days before surgery and should not be used to relieve pain afer tonsillectomy, dental extraction, or other sur- gical procedures, except under the close supervision ofa health care provider or dentist. Aspirin can potentiate bleeding from capillary sites such as those found in the GI eract (with ulcers), tomsillar beds (after tonsillectomy), and tooth sockets (after dental extractions). A single 650 mg dose of aspirin can double bleeding time, and low doses also increase bleeding time. Because ofthe effect on hemostasis, aspirin is contraindicated in patiemts with hypoprothrombinemia, vitamin K deficiency, hemophilia, history of any bleeding disorder, or history of peptic ulcer disease. Sodium salicylate does not affect platelets, butt docs increase prothrombin time, ‘The maximum 4 gram dose of sodium salicylate contains 5360 mg (25 mEq) of sodium. Consequently, patiens on strict soditm restiction should avoid using sodium salicylate; they may take magnesium salicylate instead. Patients with compromised renal function have the potential for decreased renal excretion of ‘magnesium, allowing accumulation of toxic levels when taking magnesium salicylate, The maximum 24-hour dose of magne~ sium salicylate contains 264 mg (1 mEq) of magnesium, Allsilicylates should be avoided in patients wih a history ‘of gout or hyperuricemia because oftheir dose-related effects om, renal uric acid handling, Dosages of 1 to 2 g/day inhibit rubu- lar uric acid secretion without afecting reabsorption and may. increase plasma uric acd levels, which can precipitate or worsen a gout attack. Moderate dosages of co 3 g/day have litle eect ‘on uric aid secretion, More than 5 g/day may decrease plasma uric acid by increasing its renal excretion, bue because these are toxic salicylate doses, they should not be used in the clinical management of gout or hyperuricemia, Reye'ssyndrome is an acute illness occurring almost exchu- sively in children 15 years of age or younger. The cause is un- known, but viral nd toxic agents, especially salicylates, have been associated withthe syndrome. The onset usualy fllows a vital infection with influenza (eype A or B) or varicella zoster (ie., chickenpox). Reye's syndrome is characterized by pro- gresive neurologic damage, fay liver with encephalopathy, and hypoglycemia. The mortality rate may be as high as 50% ‘The American Academy of Pediaties, FDA, the Centers for Disease Control and Prevention, and the Surgeon General have issued warnings that aspirin and other salicylates (including bis- ‘muh subsaieylate and nonaspirin slicylates) should be avoided in children and young adults who have influenza or chickenpox. ‘The following contmsindication islisted on labels of nonprescrip- tion aspirin and asprin-containing products: Aspirin should not be used in children and teenagers for viral infections, with of withoue Fever, because of the risk of Reye's syndrome with concomitant use of aspirin in cerein viral illneses, Although a simple vial upper respiratory infection (e.g, a com ‘mon cold) is not a contraindication to aspirin ws, it can be diff cult to diferentate symptoms ofthis type of infection from those ‘of influenza and chickenpox, Many clinicians, therefore, recom mend a conservative approach of avoiding aspirin whenever symptoms resembling those of influenza are present. The use of axpirin asa pediatric antipyretic has all bur ceased in the United, States, as have repors of Reye's syndrome. Since 1999, FDA hus required a warning label regarding, alcohol use on all nonprescription analgesie/antipyretic products foraduleuse. Concurrent use of aspirin with alcohol increases the risk of adverse GI events, including stomach bleeding. Patients who consume three or more alcoholic drinks daily should be counseled about the risks and referred to their primary care provider before using aspirin, ‘Combination Products Many nonprescription analgesics are available in combination products (Table 5-8). The efficacy of caffeine/analgesic combinations has been demonstrated fora variety of conditions, including tension-type and migraine headaches.* However, these products have the potential to cause medication-overuse headache with frequent use, Combination dosage forms containing a decongestant and cither acetaminophen or an NSAID are also available, Such com binations appear logical for use in sinus headaches or other indi- cations for which both analgesia and decongestion are needed. Inaddition, enhanced analgesia has been reported for various antihistamine analgesic combinations, including omphenadrine/ acetaminophen and phenylolosamine/acetaminophen, Alchough‘Trade Name Primary Ingredients Adull Cold & Sinus Caplets and Ligui-Gels Ibuprofen 200mg: ‘Peeudoephedhne 30mg Aleve-D Naproxen sodium 220 mgi ‘Pseudoephedrine 120 mg Acetaminophen 250 mg; ‘phenlepivine S mg ‘Acetaminophen 250 mg; ‘aspirin 250 mg; caffeine e5mg ‘Acetaminophen 250 mg: ‘aspirin 250 mg; cafemne ‘Alka Sezer Plus Sinus Formula Etfervescont Tablets Anacin Advanced Headache Formula Costed Tablets Excedein Migraine tablets o5mg extra Strength Bayer Back and Aspirin 500 mg; caffeine Body Pan Coated Caplets 825mg Excedrin Tension Headache Acetaminophen S00 mg; Geltabs caffeine 65 mg Goody's Extra Svength Powder Acetaminophen 260 ma; ‘aspirin 520 mg; caffeine s25m9 ‘these combinations have demonstrated superior efficacy in acute pain, compared with acetaminophen alone, their uses imited by the sedating effects of the antihistamines, Pharmacotherapeutic Comparison ASPIRIN VERSUS NONACETYLATED SALICYLATES [Although definitive clinical data are lacking, aspirin and non acetylated salicylates are believed to be equal in anti-inglammatory potency; however, aspirin is thought to bea superior analgesic and antipyretic.” ASPIRIN VERSUS ACETAMINOPHEN Numerous controlled studies have demonstrated che equivalent analgesic efficacy of aspirin and acetaminophen on a milligram ‘for-milligram bass in various pain model, including postopen- tive pain, cancer pain, episiotomy pain, and oral surgery pain. In a placebo-controled tial involving 542 patients, single doses of acetaminophen 500 mg and 1000-mg were compared with single «doses of aspirin 500 mg and 1000 mg forthe treatment of tension type headache. Two hours afer taking the study medication, Doth aspirin groups and the acetaminophen 1000 mg group, produced superior pain relief compared with placebo, Although the study was not powered to detect differences between, active treatment arms, the percentage of patients reporting ade- ‘quate oF cotl relief was simi among these three groups." ASPIRIN VERSUS IBUPROFEN Ibuprofen bas been shown to be at least as effective a aspirin in treating various types of pain, including dental extraction pai dysmenorthea, and episiotomy pain. Because aspirin must be dosed near the self-care maximum to achieve ani-in flammatory effects, NSAIDs may be prefered forse treatment of nlamma- tory disorders such as theumatoid arthritis or acute muscle injury. Headache CHAPTER 5 75 [NSAID VERSUS ACETAMINOPHEN For episodic tension-type headache, acetaminophen 1000 mg. appears to provide relief thats equivalent to naproxen 375 mg." For moderate-to-severe (dental or sore throat) pain in children, single doses of acetaminophen 7 to 15 mg/kg produced similar pain relief, compared with ibuprofen 5 to 10 mg/kg. Both drugs ‘were well tolerated! [NAPROXEN VERSUS IBUPROFEN [Naproxen sodium 220 mg appears co be similar in efficacy to ibuprofen 200 mg, The onset of activity is similar between the two NSAIDs. Naproxen's duration of action is somewhat longer than that of ibuprofen, but the clinical significance of that difference is not clear. Nonetheless, some patients report better response to one NSAID than t0 another for reasons hac are unclear Product Selection Guidelines SPECIAL POPULATION CONSIDERATIONS ‘Age isan important consideration in the selection of an appropri- ate nonprescription medication for sel-reatmene of headache. Parents of children younger than 8 years should seek the advice of their pediatrician before embarking on sel-treatment. Children 2 years and older may use acetaminophen or ibuprofen, and naproxen has been approved for use in patients atleast 12 years of age. Parents should not use aspitin or aspirin-containing prod- ucts in children ages 15 yeats or younger, unless directed to do so by a primary care provider, because of te risk for Reye's syndrome, Persons of advanced age ae at increased rk for many adverse cffees of salicylates and NSAIDs, Comorbidivies, impaired renal fanction, and use of other medications may contribute to the increased risk, In particular, older adults are more vulnerable 0 serious GI toxicity,” as well as to the hypertensive and renal efeces of these agents. For this reason, acetaminophen is gener- ally recognized as the treatment of choice for management of ‘mild-to-moderate pain in older adults: ‘When peripheral ani-inflammatory activity s not needed and asprin’seffeee on hemostasis is a concern, acetaminophen isan appropriate analgesic for self-medication. Prescription sl- Jcylate compounds sakalate and choline magnesium eriicylace ddo not have appreciable effects on platelet aggregation and are reasonable alternatives when a peripheral ant-indammatory agent is indicated, ‘Acetaminophen crosses the placenta, but it is considered safe for use during pregnancy." Ie appears in brease milk, producing a smilk-to-maternal plasma ratio of05:1.0. On the basis of | gram ‘maternal dose, the estimated maximum infant dose is 1.85% of the maternal dose. The only adverse effect reported in nursing. infants exposed to acetaminophen through breastmilk i rarely ‘occurring maculopapular rsh, which subsides when drag expo- sure is discontinued. Acetaminophen use is considered compati- ble with breast-feeding, ® No evidence exists that NSAIDs are teratogenic in either humans or animals, However, use of these agents is contraindi- cated during the third trimester of pregnancy, because all potent prostaglandin synthesis inhibitors can cause delayed parturition, prolonged labor, and increased postpartum leeding. These agents can ako have adverse fetal cardiovascular effects (eg, premature closure of the ductus arteriosus). Lactating women taking up {0 2.4 grams of ibuprofen per day showed no measurable excre~ sion of ibuprofen inco breast milk, and ibuprofen is considered76 SECTION 11 _ Pain and Fever Disorders compatible with breast-feeding. Naproxen is alo considered compatible with breast-feeding ® ‘Women should be advised to avoid aspirin during pregnancy, specially during the last trimester, and when breast-feeding Aspirin consumption during pregnancy may produce adverse maternal effects, including anemia, antepartum oF postpartum hhemorthage, and prolonged gestation and labor. Aspirin ingestion ‘on a regular basis during pregnancy may increase the rsk for com plicated deliveries, including cesarean sections a well as breech and forceps deliveries, However, definitive data supporting this concer are lcking, In 1990, FDA required oral and rectal non= prescription drug products chat contain aspirin to carry labels that ‘war agains using che drugs during the last 3 months of pregnancy tunes the patient is directed to do so by a medical provider, Aspirin readily crosses the placenta and can be found in higher concentrations in the neonate than in che mother. Sai- cylate elimination is slow in the neonate because of the liver’ immaturity and underdeveloped capacity to form glycine and glucuronic acid conjugates, and because of reduced urinary texctetion resulting from lowe glomeruls filtration rates. Fetal effects of in ucero aspirin exposure include intrauterine growth retardation, congenital salicylate intoxication, decreased albumin-binding capacity, and increased perinatal mortality. In utero morality results, in part, from antepartum hemorrhage or premature closure of the ductus arteriosus. In utero aspirin expo~ sure within 1 week of delivery can produce hemorrhagic episodes and/or pruritic rsh in the neonate, Reported neonatal bleeding complications include petechiae, hematuria, cephalhematoma, subconjunctival hemorshage, and bleeding afer circumcision, An rreased incidence of intracranial hemorrhage in premature of low-birth-weight infants has also been reported after maternal aspirin use near birth. The relationship between maternal aspirin ingestion and congenital malformation is unresolved. An asoci- ation between maternal apitin ingestion, oral clfis, and congen- ital heare disease has been reported, However, other studies have failed to confirm increased sk for feeal malformation resulting from maternal aspirin exposure, Aspirin and other salicylates are excreted into breast mill in low concentrations. After single-dose orl salicylate ingestion, peak milk levels occur at about 3 hours, producing a milk-to~ maternal plasma ratio of 3:8, Although no adverse effects on platelet funetion in the nursing infant exposed co aspirin through the mother's milk have been reported, these agents stil must be considered a potential risk.” Patients with renal impairment should exercise caution when using salicylates. Clinically important alterations in renal blood low resulting in acute reduction in renal fumetion can result from use of even short courses of salicylates. These patients should be referred for medical evaluation for assistance in selecting an analgesic. PATIENT FACTORS Nonprescription analgesics are available in a number of dos- age forms. During the patient assessment, clinicians should determine which dosage form will provide the patient with an optimum outcome. Ifrapid response is desired, chen immediate- release oral dosage forms would be preferred over coated oF extended-release forms. For patients experiencing migraine headache with severe nausea, rectal dosage forms may be pre- ferred. Analgesic/decongestane combination products should be discouraged in patients with frequent migraine, because nasal congestion may be a consequence of trigeminal nerve activity during the headache and because of the potential for rebound congestion with frequent use. ‘Use of acetaminophen in the pediattic population is compli- ‘cated by the various available strengehs and formulations. Un- intended over- or underdosing can occur when parents switch Derwveen infant crops (80 mg/01.8 mL) and elixir (160 mg/5 mL), incorrectly assuming that they are the same concentration. In addition, rapidly growing infants quickly outgrow previous dose requirements. Therefore, recalculation of the pediatric dove econfingo pee age ad body weights appropriate at Patients with significane alcohol ingestion (more than two drinks per day) should avoid self treatment with nonprescription, analgesic. Patients intolerant to aspirin may also cross-react with other ‘chemicals or drugs. Up to 15% of patients who are intolerant to axpirin may cross-react when exposed to tartrazine (Food Drug, land Cosmetic Yellow Dye No. 5), which can be found in many. «drugs and foods, Cros-reaetion rates for acetaminophen, bupro- fen, and naproxen in documented asprin-incoleran patients are 7%, 98%, and 100%, respectively.** High eross-reaction rates, are abo reported with some prescription NSAIDs. The proposed, mechanism of cross-sensitivity between aspirin and NSAID ‘involves shunting arachidonic metabolism down the lipoxygenase pathway (because of inhibition of the COX pathway, resulting in accumulation of leukotrienes that can cause bronchospasin and anaphylaxis. Therefore, patients with a history of aspirin, incolerance should be advised to avoid al aspirin- and NSAID- ‘containing products, and to use acetaminophen preferentially for analgesic self-medication. PATIENT PREFERENCES ‘One atea in which the clinician can be instrumental in affect ing outcomes is in determining which dosing frequency will ‘be needed for an individual patient. Naproxen can be taken, two co three times daily and may improve patient adherence. Conversely, acetaminophen, ibuprofen, and salicylates may. require dosing as frequently 4s every 4 hours. Because of the delayed absorption of sustained-release aspirin, such produces are not usefal for rapid pain relief but may be useful as bed= time medication Complementary Therapies Feverfew, butterbur, and topical peppermint oil are the most ‘commonly used natural produets for headache (Table 5-9). (See ‘Chapter 54 for further discussion of these products.) ‘Acupuncture has been used to prevent migraine and tension-type headache. Evaluation of acupuncture s complicated by dificules in blinding and differences in identifying acupune- ture points, Overall, results have been variable, bue several randomized, placebo-controlled trials found acupuncture effective in reducing frequency and severity of headache." Assessment of Headachi ‘A Case-Based Approach Before self treatment of headache can be recommended, the clinician must assess the patient’ headache—the type, severity, location, frequency, intensity over time, and age a onset—and, ‘obtain a medical and psychosocial history. All current medica~ tons should be inventoried, and all past and present headache ‘treatments should be reviewed, with emphasis on determining, which treatments, if any, were successful or preferred.Headache CHAPTER 5 7 Agent Risks Use/Etfectiveness Botanical Medicines (Scientific Name) Butterbur (Petasteshybridus) Belching; avoid during pregnancy and lactation: ‘avoid products with UPA constituents; UPA ‘roe products seem safe for use s16 weeks Possible rebound headache with chronic use; ‘mouth ulceration with direct contact with leaves; possible anticoagulant effect ‘Skin irtation at application st; avoid during pregnancy and lactation Feverfew (Tanacetum parthenium) Peppermint oll (Mentha piperita) Nonbotanical Natural Medicines Coenzyme O10 ‘Avoid during pregnancy and lactation; minor GI disturbances most common sde effets Nutritional Supplements Magnesium Diarthea; Gl upset Ribofiavin Diarrhea; polyuria Prevention of migraine headache; PC RT demonstrated 250 mg/day may reduce frequency by -50%, ‘Treatment and preventon of migraine headache; ‘mixed aus om clinical was, possibly because of diferencs in formulations Topica treatment of tension headache: pre- liminary evidence suggests peppermint cil applied to forehead and temples may relieve tension headaches, Prevention of migraine headache; small, open abel tal demonstrated 150 mg/day reduced frequency by -23%, ‘Treatment and prevention of migraine headache °C, bnded RTs of 20-24 mmolsy yielded ‘mined results for prevention; patients with hypomagnesemia may respond to IV magne- slum administered during scuteatack Prevention of migrtine headache; small RT of 400 mg/day showed reduced frequency of migraine headaches, Key: Gl, gastrointestinal lv, intravenous; PC, placebo-contrlled; RT, randomized tril; UPA, unsaturated pyralizdin alkaloid, Secondary headaches other than minor sinus headache are ‘excluded from self-eeatment. Headache associated with seizures, confusion, drowsiness or cognitive impairment may be asign of | Drain tumor, ischemic stroke, subdural hematoma, orsubarach- noid hemorthage. Headache accompanied by nausea, vomiting, fever, and stiff neck may indicate brain abscess or meningitis Deen eer) See’ Headache with night sweas, aching joints, fever, weightloss and visual sympeoms (such as bluring) in patients with sheumatoid arthritis may indicate cranial anertis. Headache associated with Tocalized facial pain, muscle tendemess and limited moxion ofthe Jaw may indicate temporomandibulr joint disorder. ‘Case 5-1 illustrates assesment of a patient with headache. CASE 5-1 Information Gathering 1. Gather essential information about the patient's symptoms, including: 2. description of symptom. ature, onset duration sever, asiodated simetoms) description of any factors that seem to precipitate, exacerbate, and/or relieve the patient's symptoms) ‘description of the patient’ efforts to relieve the symptoms | Patient describes occasional headaches that tend to occur during work, which are characterized by threbbing pain that comes on suddenly toward the end of her shift. hough sheis able to continue working, se fees nauseated and is not as, productive, Her work schedule consists of four midnight shifts per week, and she has noticed ‘hather headaches tend to occur onthe fist one or two nights, Bright sunlight on her dive home worsens the pain. Going to sleep after she comes home helps resolve the pain ‘Atrial of acetaminophen 650 mg during two separate headaches didnot improve her symptoms,78 SECTION 11 _ Pain and Fever Disorders CASE 5-1 (continued) 2, Gather essential patient history information 2. patient’ identity be patient's age, sex height, and weight patient's occupation d. patient’ dietary habits «patient's sleep habits {. concurrent medical conditions, prescrip tion and nonprescription medications, and dietary supplements g.allegies hy history of other adverse reactions to ‘medications |, other (describe) Assessment and Triage 3. Differentiate the patient’ signs/symptoms and correctly identify the patent's primary problems) (see Table 5-1), 4, identify exclusions fr seltreatment (ee Figure 51), 5. Formulate a comprehensive lst of therapeu tic alternatives forthe primary problem to determine if riage toa medical practioner Is required, and share this information with the patient, Plan 6. Select an optimal therapeutic alternative to address the patient's problem, aking into Account patent preferences. 7. Describe the recommended therapeutic approach tothe patient 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic attematives. nt Education 8, When recommending self-care with non prescription medications and/or nondeug ‘therapy, conway accurate information tothe patent: 2. appropriate dose and frequency of ‘sdminstration eee key Heather Moran 26-year-old female, 55 in, 14015 Respiratory therapist in an intensive care unit a a ight at wor ‘Sleeps about 7 hours during the moming and eary afternoon ater each work shift, bbutthe sleep is restless and often fragmented. he sleeps about 10 hours per right on nights she s not working and feels this sleep ts much more restorative, ‘She was diagnosed with migraine headache 6 monthe ago and has prescription ‘aborive therapy sumatriptan. Although she has used it and experienced reli ‘rom her headache, she prefers not to take it because of concems about side ‘effects and high cost She has seasonal allergies and uses nonprescription lorata- ine at needed, She uses oral contraception; her last menstrual period was 2 weeks ago. KA, ‘Sumatrptan worsens nausea. Diphenhydramine causes excessive drowsiness Ms, Moran is experiencing episodic migraine headache possibly elated to shifting sleep pattems. Ms. Moran has no exclusions for self-reatment. Options include: (1) Refer for medical evaluation. {@) Recommend a nonprescription analgesic {@) Suggest nondrug measures, alone orn combination with drug therapy. (@) Take no action Normalizing her sleep schedule might help Ms. Moran reduce the frequency of. thor migraine headaches. Specifal, sleeping during the same hours each day, regardless of whether she Is working, might help. Because her pain isnot severe (Ghe is ble to continue working), nonprescription analgesics can be used. Aceta- ‘minophen should be avoided because itis generally not recommended for ‘migraine headache, and because she has already tied it and found no elie, ‘Your headaches seem to be caused by your ireguar sleeping habits. Try to adjust your sleep times so that they are the same each day, rather than sleeping at night ome days and in the moming/aftemoon other days. When headaches occur, take ibuprofen, naproxen, or aspirin early in the course ofthe headache, Most mild or moderate migraine headaches respond to self-reatment. Although ‘any nonprescription product containing an NSAID or salicylate could be helpful, ‘void using combination products containing caffeine, because you already ‘consume liberal amounts of caffeine during your work shift Naproxen 220 mg 1 tablet atthe frst sign of headache, and every 8 hours if you ‘need it. Do not take more than 3 tablets in 24 hours.Headache CHAPTER 5 79 SE 5-1 (continued) Pen eee tay Cornette maximum number of days the therapy should be employed «. product administration procedures expected time to onset of lief «. degree of relief that can be reasonably expected 4. most commen side eects Use nonprescription analgesics upto 3 days per week, “Take it as soon as possible after the start ofa headache, Pain relies expected to begin in 30-60 minutes. “Many people report a noticeable lessening ofthe pain. Complete resolution of headache s possible, ‘Watch fr stomach upset, stomach pain, and worsening of your nausea with naproxen. Taking it with some food can help if your nausea doesnot prevent you from doing that. Stop using naproxen and seek medical attention if you have severe stomach pain, ‘throw up Blood, or have back stools f you have rash or hives, or red, peeling ski, ‘or sweliing inthe face or around the eyes; if you develop wheezing or rouble breathing; orf you have unexplained bruising and bleeding, If raproxen isnot helpful for your headaches, then try ibuprofen or aspirin. you {9:Side effects that warant meclcalinterven- tion should they occur h. patient options in the event that condition ‘worsens or persists need medicine for your headaches more than 3 days per week, then see your medical provider. 1. product storage requirements Keep your nonprescription medicines ina tightly closed container and away from children. J. specific nondrug measures See comments instep 6 regarding improving your sleep habit. 10. Solicit follow-up questions fom patient. Why cant take medicines more than 3 days per week? 11, Answer patient's questions. Using headache medicines more than 3 days per week can cause rebound headaches. Also, frequent headaches may be better reated wih preventive rmacicines that are available by prescription only. Key: NKA, no known allergies. factors that can improve headache prevention and ereatment. Patients should be advised chat continuing or escalating pain can be a sign of a more serious problem and that prompt medical attention is warranted, The box Patient Education for Headache Patient Counseling for Headache ‘To optimize outcomes from therapy, the practitioner should instruct patients to take an appropriate dose of analgesic eatly in the course ofthe headache, The use of nonprescription analgesics, to preempt or abort migraine headaches should aso be explained, to patients with migraines whose headaches are predictable. Patients who have headaches with some frequency should be ‘encouraged to keep a log oftheir headaches to document trig- ‘gers frequency, intensity, and duration of episodes and response, to treatment, This record may also be helpful in identifying, PEAT ns lists specific information to provide patents. The linician should explain appropriate drug and nondrug measures for treating headaches. Frequent use of nonprescription analgesics is not appropriate because ofthe ris for medication-overuse headache. Ie should be conveyed that nonprescription analgesics are potent ‘medications with accompanying potential adverse effects, inter- actions, and precautions/wamings. ‘The objectives ofselttreatment are to (1) relieve headache pan, (2) prevent headaches when possible, and (3) prevent ‘medication-overuse headaches by avoiding chronic use of ‘nonprescription analgesics. Carefully following product insttutions and the self-care measures listed here will help ‘ensure the best results Tension-Type Headaches 1 Nonprescription pain relievers (analgesic) are usually effective for episodic tension-type headaches. However, consult a medical provider before using aT them for chronic tension-type = headache, ‘ ® If nonprescription pain ealiov- > ye cers are used for chronic head ‘ ee aches, keep records of how ‘often they are used, and share this information with your medical provider. ' Do not use products containing caffeine because of the risk of cafeine withcraval headaches.80 SECTION II Pain and Fever Disorders Migraine Headache = Avoid substances (food, caffeine, aleohol, medication) or st- uations (stress fatigue, oversleeping fasting, ormissing meals) that you know can trigger a migraine. ® Use the following nutitiona svategies to prevent migraine: Avoid foods or food additives known ta tigger mgraines, including red wine, aged cheese, aspartame, monosodium glutamate, coffe, 2a, cola beverages, and chocolate, Avoid foods to which you ae allergic Est regulaly to avoid hunger and iow blood glucose. — Consider taking magnesium supplements, «= Fonset of migraines is precitable e.g, headache occurs du- ing menstruation, take aspirin, ibuprofen, or naproxen to pre- vent the headache. Start taking the analgesic 2 days before you expect the headache and continue regular use during the time the headache might star. |= Try to abort a migraine by taking aspirin or an NSAID at the onset of headache pain. "=f desied, use an ice bag or cold pack applied with pressure to the forehead or temples to reduce the pain associated with acute migraine attacks. Other Headaches "= Consider using a combination of a decongestant and non- prescription analgesics to relieve the pain of sinus headache. Precautions for Nonprescription Analgesics "= Ifyou are pregnant or breast-feeding, consulta primary care provider before taking any nonprescription medications. "= Obtain medical advice before taking any of these medications if youhave a medical condition or are taking prescription me ications. Nonprescription analgesics are known to interact with several medications ' Do not take these medications for longer than 10 days unless ‘8 medical provider has recommended prolonged use, ' Do not take these medications if you consume three or more alechalic beverages daly. ' Do not exceed recommended dosages. ' Products containing aspartame and/or phenylalanine (usually chewable tablets) should not be given to individuals with phenylketonuria, Solicylates and NSAIDs ' Do not take aspirin during the last 3 months of pregnancy Unless a primary care provider ie supervising such use. Unsu- ppenised use ofthis medication could harm the unborn chid or ‘cause complications during delivery ' Do not give aspirin or other salicylates to children 15 years of age or younger who are recovering from chickenpox oF influenza, To avoid the risk of Reye's syndrome, a rare but potentially fatal condition, use acetaminophen for pain reli Evaluation of Patient Outcomes for Headache Appropriate follow-up will depend on headache frequency and severity, and patient fctors. For patients with episodic headaches, atrial oF 6 co 12 weeks may be needed to assess efficacy of teat™ ‘ment, For chronic headache, follow-up afier4r0 6 weeks should be adequate to ases treatment efficacy. Forsevere headaches, cli- nicians should communicate with patients within 10 days of ini- oon) 1 Do not take aspirin or NSAIDs if you ae allergic to aspirin or have asthma andnasal polyps. “Take acetaminophen instead. 1 Donat take aspirin or NSAIDs ifyou have stomach problems ‘rulers, ver disease, kidney disease, or heart failure. 1 Donot take NSAIDs you have or are thigh risk for heart di ‘ease or stoke unless such use 1 supewised by 2 medical provider 1 Do not take aspirin if you have gout, clabetes mellitus, oF ‘arthritis, unless such uses supervised by a medical provider. 1 Donottake slcates or NSAIDs you ae taking anticoagulants "= Donot take magnesium salcyateif you have kidney disease. = Donot take sodium salicylate if you are on a sodium-estrcted diet, = Do not give naproxen toa child younger than 12 years Ay se ctg siete cr Nsebsand se nec She) ict ine ese fiadoche, cziness, ging te war, dificay in heating, canes of sion, metal confuson laste, hovaieat, sweating, thr, hyperventilation, nausea, ‘emit ofocasioal ares, These symptoms nd ‘te mid saleyst ony. —Diziness, revsea and mid stomach pain, constipation, fnging in the ears sealingin te fat or lge, These symptoms are common side effets of acylates and NSAIDS Rash orhives, or red, peeing kin; weling nthe face or pose tne eRe bret Bioody or black tay stools sovere stomach pan or oe) cons eee or erloec! bruting and bleeding. These symptoms equre me: cate ciclo ‘Acetaminophen 1 To avoid possible damage to the Iver, do not take more than 4grams of acetaminophen aday from al over-the-counter and prescription single-ingredient or combination products con- taining acetaminophen, "= Do not drink alcohol while taking this medication. 1 Follow dotage instructions for acetaminophen carefully f you have glucose-6phosphate dehydrogenase deficiency. ‘top taking acetaminophen and seek medical attention i you develop nausea, vomiting, drowsiness, confusion, or ‘abdominal pain. tiation of self-treatment to assess efficacy and tolerability In all ‘cases, the patient should seck medical attention if headaches per= sist longer chan 10 days or become worse despite sel-eeatment. Tess notable that more chan half of patients with migraine headache use only nonprescription medications, despite the severity of pain.* Patents with migraine headaches thae are not adequately sel-treated should be referred for'a medical evalua ton because effective prescription therapies are available that ‘ean substantially limit pain and disabiiey.Key Points for Headache > Most tension-type, migraine, and sinus headaches are amenable to treatment with nonprescription medications > Patients with symptoms suggestive of secondary or un- diagnosed migraine headaches should be referred for med- ical attention > Many patients with frequent headaches may improve by ‘identifying and modifying envionment, behavioral, nutri~ sional, or other triggers for their headaches, > The choice of nonprescription analgesic for an individual patient depends on patient preferences, presence of precau- tionary or contraindicating conditions, concomitant med~ lcations, cose and other facto > Pharmacists have been identified as key sources of infor smation for nonprescription analgesic users to reduce risk: for acetaminophen-induced hepatotoxicity and NSAID- induced GI bleeding, cardiovascular events, and nephro- > Use of nonprescription analgesics for headache should be limited co 3 days per week to prevent medication-overuse headache, REFERENCES 1. Smith TR, Epidemiology and impact of headache: an overview. Pim Cae ln Ofte Prat 20048125741, 2. Garsje, Von Kerf M, Simon GE Perse pi and wel being: 4 World Health Onginizton sty in primary cae. JAMA, 199828 17-3 2 Lipton RD. Migraine: epidemiology, impact, and ak cows fr progres son. endahe- 2005:45(upp )S3-13. 4. Mannie LK: Headache epidemiology and impac of primary headache order. Med Cl Non A. 201 858857-98, 5. Consume uninformed about nonprescription pain reliever. Am J Hei Sy Ma. 199835:2577, 6 Headache Chaitin Subcommiice of the Intemational Hexdiche Society. The iterstionalchasieation of heaicke donde, 2 eon Coal. 2004.24(upp 1-160, 7.Cady RK, Dadick DW, Levine HL, eal Sins heaache:a newrolgy, ‘tolryngslogy, allergy. and primary care contents on dings od rete Maye Clin Pre 2015 80:908-16 8. Kr JC. Tensionrtype headaches: what they ar an how to tet cer, Pi Care Cl Ofer Pr 200431-293-31. 9. Sehneber CP. The pathophysiology of primary headache, Pri Cae tin fi ha. 200653126176 10. Diener H-C, Limmth V. Metiction-overse headache: workwide problem, Laet Nol 2006;3:475-83. 11, Want TN. Mediction overoe headache. Phin Care Cir Oe Pra. 2008;31:360-8. 12. Loder E- Migraine diagnosis and eaten. Prin Cire Clin Oe Pra 2008 31:277-92 13 Lipton RB, Bagg JS, Steware WE, etal. Eficacy and afty of act aminophen in the sextment of migine. Arch Tien Me. 200: 160: 14 Stine T}, Lange, Vocer M Astin in soc enson-sype headache: ceo 100.4°F (38.0°C) 66-380) onl 95975-9957 >99.7°F 37.6°C) 55°C-37.5°C) Pallary 94.5°F-99.2°F| D99.3°F 374°C) earc-a73¢) Tympanic 963°F-99.9 > 100° (37.8) @7°C-37.7°0) ‘Source: References 15 and 19.86 SECTION 11 _ Pain and Fever Disorders fom the Enviconmental Protection Agency's (EPA'S) postion fon reducing the number of mercury-based products in the United States.” Many states have banned the sale of mercary- in-glass thermometers, and many real pharmacies have volun- tarily phased out the sale ofthese thermometers, Along with EPA, the American Academy of Pediatrics aso supports the climination of these thermometers.” Practitioners should not recommend mercury-in-glass thermometers fr use a this point. ‘To properly dispose of these thermometers, patients an clinicians should contact theie local municipality Electronic probe thermometers are available for ora, rec- tal and axillary temperature measurements. The probes have an electronic transducer that provides a temperature reading in about 10 to 60 seconds. The oral electronic probes are available in both pen and pacifier shapes. The pacifier-shaped electronic thermometer is for oral use only and takes about 2 minutes to provide a reading, but itis useful in infants who are unable to hhold probes under their tongue. The pen-shaped probe may be used in the ora, rectal, or axillary area. Advantages ofthe elee- tronic thermometers include quick readings and the elimination of gas breakage, mercury toxicity, and risk of cut. The use of disposable probe covers with these thermometers also elimi- nates the need for disinfection after their use. In addition, the clectronic digital temperature display makes these thermome- ters easier to read than the traditional glass thermometers. Most electronic thermometers require batteries and may need to be calibrated periodically, Because calibration is difficult to do accurately with home use, it may be preferable for patients to purchase a new thermometer of eall the manufacturer's ews Infared thermometers are avaiable for tympanic and tempo~ ral temperature measurements. These thermometers use infared technology to detect heat from the arterial blood supply. There- fore, they must be placed directly in the line of a blood supply, whether near the temporal artery or the tympanic membrane. Infrared chermometers measure body temperacure in less than 5 seconds and are considered very accurate, i used appropriately ‘The major problem with these thermometers is that they are not alkvays placed appropriately and consequently may give inaccu- rate readings. The tympanicand temporal thermometers are rel- atively expensive and require batteries, but many families with young children prefer them because of their convenience and Color-change thermometers are easy t0 use; however, they are not sufficiently accurate or reliable. The thermometer isan adhesive trip containing heat-sensiive material that changes color in response to different remperacure gradients. The strip ‘may be placed anywhere on the skin, but the forehead is used 'most often; skin has less variation in temperature than other parts of the body. Although this method may detect changes in kin temperature, it does not reliably detect changes in core temperature. Skin temperature is influenced by many factors, including temperature ofthe environment and skin perfusion. Color-change thermometers may be use in noting tempera- ture tends but not absolute temperature Different eypes of thermometers may be used through dif ferent routes to detect temperature. Each thermometer should be used correctly to obtain an accurate reading, Patient-related factors may preclude the use ofa particular type of thermome- ter through a given route. Although there area variety of routes of eemperature measurement, rectal temperature measurement still remains the gold standard because ofits reliability and accu~ racy. Oral, tympanic, and temporal routes ae all appropriate for temperature measurements, given chat the proper procedure is followed. Table 6-3 describes the proper methods of taking oral ‘measurements with electronic thermometer.” Oral temper- ature should not be obtained when an individual is mouth, breathing or hyperventlating; has recently had oral surgerys i, not fly alert; or is uncooperative, lethargic, oF confused. Oral digital probe thermometers may not be appropriate for use in most children younger than 3 years. Children this young may find i difficult co maintain atighe seal around che thermometer and keep the thermometer under the tongue, in which case pacifier thermometers may be recommended, Pacifier ther- mometers provide reliable temperature readings with a sensi- tivity of approximately 72% and specificity of 98%, compared ‘with rectal measurements; however, in children younger than 3 months, pacifier thermometers are les accurate”?! Sensitiv- ity is defined asthe ability of the test to correctly identity indi- viduals who have a fever, whereas specificity is defined as the ability ofthe test co accurately identify those who do not have a fever, To ensure reliable measurement, the patient should neither engage in vigorous physical activity nor heat nor cool the oral cavity artificially by smoking or drinking hot or cold Deverages for a minimum of 20 minutes before temperature is, ‘measured, Table 6-4 describes the proper methods of taking rectal temperatures in children and adults, Rectal eemperature meas- ‘urement is the standard because of is predictable rise and high sensitivity and specificity, compared with the body's core tem perature, Although the rectal route isthe closest estimate of the ‘core temperatute it intrusive nature can be very fightening 10 young children. In children younger than 6 months, however, rectal temperature is the preferred method of estimating fever and should be recommended if feasible. Risks asociated with Digital Probe 1, Wat 20-30 minutes ater drinking or eating. 2, Place a clean disposable probe cover over ip 3, Tum on the thermometer and wai unt its ready fr use, 4, Place ip of thermometer under tongue, 5, Close mouth and breath trough nose 6, Hold thermometer in place until it eps and temperature has ‘been recorded (usualy after $20 seconds} 7. Record the displayed temperature. 8, Remove and dispose of probe cover. Digital Pacifier Thermometer 1, Wait 30 minutes after drinking or eating, 2, Inspect the pacer fr any tears o cracks. Do not use if worn. 3, Press the button to tun on thermometer. 4, Place the pacifier in child's mouth 5. Have the child hold pact in mouth without moving if possible {or spectied time on packaging of thermometer [2-6 minutes). 6, Record temperature when thermometer beeps. Source: Reference 19See atu eens ‘onic Thermometer Measure 1. Cover the tip of thermometer witha probe cover. 2. Turon the thermometer and wait untl itis ready for use. 3. Apply a water-soluble lubricant o tip of thermometer to alow for easy passage through the anal sphincter and to reduce the Fisk of trauma. 4. Forinfants or young chilren, pace child face down over your lap, separate the buttocks with the thumb and forefinger of ‘one hand, and inser the thermometer gently in the dection ‘of the chie’s umbilicus withthe other hand. Forinfans, insert the thermometer to the length of the tip. For young children, insert it about 1 inch into the rectum. 5. For adults, have the patient lie on one side with the legs flexed to about a 45° angle kom the abdomen. Insert the tip (05-2 inches into the rectum by holding the thermometer (05-2 inches away from the tip and inserting it unt the finger ‘touches the anus. Have the patient take a deep breath during this process to facilitate proper positioning of the thermometer. 6. Hold the thermometer in place until it beeps and a tempera tures displayed. 7. Remove the thermometer. Clean by wiping away from the stem toward tip. 8. Dispose of probe cover and clean and disinfect the tip with an antiseptic such as alcohol ora povidonetiodine solution and ‘nse with cool water. 9. Wipe away any remaining lubricant from the anus. taking a rectal temperature include retention of the thermome~ ter, rectal or intestinal perforation, and peritonitis. The patient should never be lef unattended while the rectal thermometer ‘remains in place, because a positional change may cause the ther- ‘mometer to be expelled or broken, Rectal temperature mea~ surement is relatively contraindicated in patients who are neutropenic, have had recent rectal surgery or injury, or have rectal pathology (e.g., obstructive hemorthoids or diarrhea). Rectal temperature measurement is slow to measure changes in body temperature because of the large muscle mass and poor blood flow to the area; therefore, the thermometer must be lef in place longer compared withthe oral and axillary route." ‘The mose common sources of error in rectal temperature mea~ surement include stool impaction and poor technique in taking, the temperature." Table 6-5 deseribes the proper method of wsing eympanic thermometers, which varies slightly, depending on the age ofthe patient.” Tympanic thermometers have digital readouts, and, ‘many can be set to provide either a recel or an oral temperi~ ture equivalent, The tip of the tympanic thermometer, which is placed in che ear canal, measures body temperature by sens- ingiinffared hea from the blood vesesin the eardrum. The sym= ppanic membrane is close to the hypothalamus, and the blood. supply to these two anatomic areas is atthe same temperature, providing an accurate reading of the body core temperature. ‘The thermometer must be positioned in the ear canal properly to ensure that che measured infrared radiation is from the tym~ panic membrane and not from the ear eanal or adjacent areas, CHAPTER 6 87 Fover TABLE 651 re Tympanic Temperature 1. Place a clean disposable lens cover over ear probe. 2. Turn on thermometer and wat unt tie ready for use 43, For children younger than 1 year, pull ear backward to straighten ear canal. Place ear probe into canal, and aim the ‘up ofthe probe toward patient's ay. 4. For patients older than 1 year, pul ear backward and up to straighten ear canal. Place the ear probe into canal, and aim the tp of probe toward patient's eye. 5. Press the button for emperature measurement (usualy for only 1-5 seconds} 6. Read and record temperature 7. Discard lens cover. Source: Reference 19. {In clinical erils, accuracy of tympanic thermometers has varied, compared with the recel and orl routes.” Variations in tem= perature assessment have been attributed to cerumen impaction, inflammation in the ear canal (otitis media), age of patient (size of ear canal), and inappropriate technique.” Comparisons of tympanic and rectal measurements showed tympani measure- ment to be 94,896 0 10096 specific but only 58% to 68.3% sen sitive for fever detection.2* Tympanic thermometers are not recommended in infants younger than 6 months, because their car canals are not developed fully, leading to inappropriate technique and inaccurate readings. However, if used cor- rectly, tympanic thermometry is found to be more reliable than axillary or oral thermometry in measuring core tempera- ‘ure in adults ‘Temporal thermometers are placed on the sie ofthe fore hhead directly over the eemporal artery and moved across the forehead (Table 6-6). The temporal artery is one of the few arteries close enough to the skin surface to detect heat changes. ‘The thermometer is capable of providing a temperature read ing in a few seconds. Its rapid, noninvasive nature makes it a preferable route of temperature measurement, and the temporal 1. Disinfect thermometer by drawing it through a swab mois- ‘ened with an antiseptic such as aleahol or povidone/iodine: solution 2. Place probe on one side of forehead (near temporal areal ‘Tum on thermometer and wait until it ready for use, 4, Sweep thermometer across haine to other side of forehead. Ensure that probe remains in contact wth kin at al times 5. Lift thermometer from forehead, and read and record ‘somperature. 6, Turn off thermometer. Source: Reference 2988 SECTION 11 _ Pain and Fever Disorders thermometer is significantly more sensitive than the tympanic thermometer for detecting fever.:” However, compared with rectal temperature measurement, temporal measurement s close to 100% sensitive but has variable specificity (40%-86%), which Indicates that rectal eemperature measurement i still the most accurate, Temporal temperature measurement may differ from rectal temperature measurement by £1,3°C (2.3°F).""” The presence of hair near the temporal area may confound the tem perature reading, so hair must be pushed away before a reading. 's obtained. ‘Asillary temperature measurement performed with clec- tronic thermometers (Table 6-7) is not recommended rou- nely because, compared with the oral and rectal routes, it is not as reliable for detecting fever. In clinical studies, axillary emperature measurement was found to be only 63.5% t0 75% sensitive and 64% to 92.6% specific in detecting fever, compared with rectal measurement. Large variations in temperatures have been reported with axillary measurements actriburable co inappropriate placement of the thermometer, ‘movement of arms during measurement leading to a poor seal around the thermometer, and measurements taken for a shorter period.** Axillary temperature should not be taken directly afer vigorous activity or bathing, because both can affect body temperature. Ifa fever is detected using the axil- lary method, a confirmation reading using another method is recommended. The presence of fever isa cause of great concem, although in most cases fever may be self-limiting and serious complica- tions are rare. In one study, 56% of caregivers were "very wor- ried” about the potential complications of fever, and 34% were “somewhat wortied.” There is less concer abou complications of fever now than 20 years ago; however, 67% of interviewed caregivers still st seizures, brain damage, and death a che main complications of fever." Overall, the major risk of fever are rire but may include acute complications such as seizures, dehydra- sion, and change in mental status Febrile seizures are defined as a seizure accompanied by fever inthe absence of another cause such asan acute metabolic disor- der of CNS inflammation, These seizures occur in 2% to 5% of all children from the ages of months to 5 years. The most ‘common seizures asociated with fever are simple febrile seizures, which are characterized by nonfocal movements, generally ofless than 15 minutes in duration. Significant neurologic sequelae (impaired intelleceual development or epilepsy) are unlikely afer a single pediatric febrile seizure. High, rapidly increasing temperatures have been asociated with febrile seizures. Although both the magnitude and rate of temperature increase appear to be critical determinants in precipitating febrile seizures, the temper- 1. Place a clean disposable probe cover over tp. 2. Turn on thermometer and wait unt tis ready for use 43, Place tip of thermometer in armpit. Ensure that armpit is clean and dry, Thermometer must be touching kin, nat clothes. 4 Hold child close to secure the thermometer under armpit, if necessary. '5, Read and record temperature when thermometer beeps ature at which a particular child will seize is unpredictable. Most inigal febrile seizures occur in children younger than 3 years. Seizures occurring after that age are usualy unrelated to fever. ‘The risk of recurrence is increased in children who have experi- enced a previous febrile seizure (especialy iit occurred before 1 year of age or was a complex febrile seizure), in chikren who hhave documented seizure or other CNS disorder, or in those whose family history includes febrile seizures." Prophy. axis against simple febrile seizures with antiepileptic or anti- pyretic drugs isnot recommended by the American Academy of Pediatrics. Serious detrimental effects (eg, dehydration, delirium, seizures, coma, irreversible neurologic, or muscle damage) ‘occur more often in patients with hyperpyrexia [temperatures ‘greater than 106°F (41.1°C)], which is usually associated with hyperthermia and not fever. Iris are cha afebrile person will have temperatures exceeding 106°F (41.1°C) owing to the homeostatic mechanisms of the hypothalamus. However, even Tower body temperature elevations may be life-threatening, in patients with heart disease and pulmonary dysfunction, Increased risk of complications exists in infants and patients with brain tumors or hemorrhage, CNS infections, preexist- ing neurologic damage, and decreased ability to disipate heat attributed t0 lower tolerance of elevated body temperature Patients of advanced age are at a higher risk for fever-related ‘complications because of their decreased thirst perception and, perspiration ability.°°* Treatment of Fever Feverisa sign of an underlying proces. Treatment offever should focus on the primary cause rather than on the temperature read ing. No correlation exists between the magnitude and pattem of | temperature elevation (Le. persistent, intemmittent, recurrent, ot prolonged) and the principal etiology or severity ofthe disease. “Therefore, eis dificule to determine the cause ofthe fever on the sole bass ofthe temperature reading. Patient dscomfors sociated with fevers the main indication for antipyretic therapy, but ang ments against such treatment include the generally benign and sellimited course of fever, the posible elimination ofa diagnos- tic or prognostic sgn, the atemuation of enhanced host defenses e., posible therapeutic effect of fever), and the untoward effects ‘of antipyretic medications, ‘The decision to treat fever is based om a patient-specific risk benefit ratio, Fever increases oxyigen consumption, produc tion of carbon dioxide, and cardiac output. However, fevers not associated with many harmful effecss unless the femperacure ‘exceeds 106°F (41.1°C), and there is evidence that fever is an adaprive response and that elevated body temperature may be ‘beneficial, Certain microbes are thermolabile: therefore, their ‘growth isimpaired by higher than normal temperatures. Clinical reports suggest that treating chickenpox with acetaminophen and shinovinus with apirin may increase the duration of the symp- toms, compared with no treatment. Therefore, overtreatment ‘of fever may also be detrimental. Furthermore, low-grade fever, may have beneficial effects on host-defense mechanisms (¢ antigen recognition, T-helper lymphocyte function, and leuko ‘cyte moziiy), but these effects have not been shown to fvorably aker the course of infectious diseases” Because there is no over- ‘whelming amoune of data to support cither the beneficial or the |harmfal effects of fever, itis important to consider other patient specific factors when recommending treatment.Treatment Goals ‘The major goal of self-reatment isto alleviate the discomfort of fever by reducing the body temperature to a normal level General Treatment Approach “Treatment for fever using antipyretics Gee Chapter 5, Tables 5-2 and 5-3) is most often indicated for patiens with elevated cen peratures, accompanied by discomfort. Fever exceeding 101°F (8.3°C) orally may be treated with antipyretic agents, as well 8 nonpharmacologic measures. Treatment with antipyretics ‘may also be indicated at lower temperatures ifthe patient is, ‘experiencing discomfort or is of advanced age. Studies sug- Fever CHAPTER 6 89 ages that for each decade increase in age, average temperature Js decreased by 1.4°F (0.8°C); temperatures less than 101°F (38.3°C) may indicate fever in older populations.™ The dis- comfort associated with a fever of less than 101°F (38.3°C) ‘may be the primary indication for any of the nonprescription anupyretic medications, given that all of these agents are aso analgesics, Self-care measures, including antipyretis, are appropriate initial therapy, unles there is an exclusion for selreatment (Figure 6-1). In addition, parents of children should be urged to call their pediatrician immediately or seek urgent medical cate if heir child has a history of seizures refuses to stay hydrated: develops a rash; has a rectal temperature greater than 104°E (40.0°C); or is very sleepy, itritable, or difficult ro wake. In all Fount uihanpected fever Exclusions for Self Treatment ¥ ‘Ask ptien/cragiver how body temperature was measured Y Offer to ake patente Sy wena temperature, Explan proper Wasted tempers resned |_| ahodvalenparton accurately ‘measurements I fever present, 1 {90 to next box Obtain smnptom information, medica histor, allergy information ¥ Excision for selfveatment see ees Lves—>| Medical referl 1 Oraltemperatue =101"F 380 | | Soa baead on eat or or equivalent? preferences (see Chapter 8) Nondrug messues = antipyretic agent pent has comfort or patienvearegiver requests agent Fever resolved after 3 days of treatment? Mecca referral 1 DiC theapy tinue; HIV, human immunodeficiency virus. on of fever. Key: CNS, central nervous sytem COPD, chroie obstructive pulmonary disease: D/C,90 SECTION 11 _ Pain and Fever Disorders cases, self-care measures may be started while medical evaluation is being sought. Nonpharmacologic Therapy Nonpharmacologie therapy consists mainly of adequate fhuid ake to prevent dehydration. Sponging or baths have limited utility in the management of fever, Body sponging with tepid ‘water may ficlitate heat dissipation, because only a small temper- ature gradient between the body and the sponging medium is necessary to achieve an effective antipyretic response. However, sponging isnot routinely recommended for those with a tem perature less than 104°F (40°C); spongingis usually uncomfort- able and often induces shivering, which could further rise the temperature Ice-water baths of sponging with hydroaleoholie solutions (e.g. isopropyl or ethyl alcohol) is uncomfortable, unnecessary, and not recommended. Aleohol poisoning can result from cutaneous absorption or inhalation of topically applied alcohol solutions. Infants and children are at a higher ‘isk of alcohol poisoning because of their smaller body mass Unlike acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS), sponging docs not reduce the hypothalamic set point; therefore, sponging should follow oral antipyretic therapy by | hour to permit the appropriate reduction of the hypothalamic setpoint and a more sustained temperature-lowering response.” ‘Other nonpharmacologic interventions, regardless of the temperature, include wearing lightweight clothing, removing. blankets, maintaining room temperature at 78°F (23.6°C), and drinking suficiene aid to replenish insensible losses, Because a fever will cause a child co lose fluids more rapidly, suificient uid intake is recommended. Fluid intake in febrile children should bee increased by at least 30 t0 60 mL. (1-2 ounces) of uid per hour (e.., sports drink, ffuit juice, water, or ice pops) and by at least 61 to 120 ml. (3-4 ounces) of Buc per hour in adults, tunles ids are contraindicated. Pharmacologic Therapy Antipyretics inhibit PGE, synthesis, which decreases the feed- back between the thermoregulatory neurons and the hypothal- amus, thereby reducing the hypothalamic set point daring fever. All aneipyreties decrease the production of PGE: by inhibiting the cyclooxygenase (COX) enzyme, NSAIDs and aspirin inhibit the COX enzyme in the periphery and CNS, ‘whereas acetaminophen mainly inhibits the COX enzyme in the CNS.” Chapter 5 provides an in-depth discussion of the pharmacokinetics, dosing, adverse elect profile, intersctions, contraindications, and precautions of the antipyretic agents ‘Acetaminophen typically reaches a maximum temperature reduction at 2 hours at the usual recommended dosing of 10 co 15 mg/kg every 4 t0 6 hours with a maximum of five doses per ay (see Chapter 5, Table 5-2 and 5-3). Some clinicians have recommended loading doses of acetaminophen for the redue- tion of fever at 30 mg/kg per dose, consequent to a smal study that found a faster (one-half hour) and more significant (0.5°C [0.9°F) decrease compared with a traditional dose.* This prac- tice is not recommended, owing to the size and limitations of this study and the lack of any follow-up evidence for this prac- fice, Acetaminophen is also available asa rectal suppository Although a suppository may be an advantage for caregivers who have problems giving their children oral medications or for chil- dren who are vomiting or having. febrile seizure, ts absorption is ematic and the dosing often does not reach levels sufficient ¢o produce antipyretic activity Ibuprofen is the most common NSAID used as an anci- pyretic and typically eaches a maximum temperature reduction at hou at the recommended dosing of 5 to 10 mg/kg per dose ‘every 6 to 8 hours with a maximum of four doses per day (ee ‘Chapter 5, Tables 5-2 and 5-3). Some studies have shown that, ibuprofen may be more effective at higher doses (10 mg/kg), ‘specially when temperatures exeeed 102.5°F (39.2°C).” Ie ‘important to note that ibuprofen is approved in only patients ‘older than 6 months for the reduction of fever. Although NSAIDs and acetaminophen are safe and effec~ tive when used at low doses for a short duration, they should not be used more than 3 days to treat fever without referral for further evaluation to determine the underlying cause. In addi- tion, recent reports of medication errors and increased adverse ‘events involving these agents have led FDA to encourage health ‘are providers to take preventive actions. FDA recommends- ‘ons include a patient education campaign to decrease medica tion errors as well as to increase awareness of side effects and ccontraindications" (Table 6-8). Common medication errors include overdosing or duplicating therapy when using nmuliple products with similar ingredients, and inappropriate dosing for pediatric patients attributed to mathematical errors in caleulat- inga weight-based dose, recent study hasshown that only 30% ‘of parents were able to measure an aceurate dose of acetarnino~ pphen, whereas another study demonstrated that 51% received an. inaccurate dose of medication (62% for acetaminophen and 26% for ibuprofen)."! Because ofthese alarming statistics, is impor- tant for pharmacists to provide an appropriate measuring device and/or demonstrate to patients and caregivers proper dosing, and measurement of the medications Pharmacotherapeutic Comparison ‘To date, very few clinical tals compare the antipyreti effects, of ibuprofen and acetaminophen in recommend dosages. The ‘ils that have been completed are usually in a small number of Pe Health care providers should educate patents actively about ‘antipyretic agents, including the folowing measures: * A.wide variety of different strangths, formulations, and com: binations of acetaminophen- and NSAID-containing products ‘are available over the counter or by prescription ' Any nonprescription analgesic is a drug, and should be taken ‘and stored appropriately, Specific precautions include: = The correct dosing frequency for each of the acetamino- phen or the NSAID formulstons. — The correct weight-based dose for each child = Use ofthe correct measuring device for the liquid formulations — Risks of taking nonprescription analgesics with prescription corother nonprescription medications, — Signs and symptoms of slrecognizable side effec — Potential problems associated with simutaneous use of more than one pain-elief product. Key: NSAID, nonsteroidal ant-inflammatory drug. Source: Reference 40patients with various dosages, making conclusions on superior- ity of one agent difficult. A recent review of 14 clinical wis ‘comparing ibuprofen and acetaminophen in febrile children did find tha ibuprofen was slightly more effective than acetansino~ pphen in reducing fever afier a single dose and furthermore was, Found to be more effective after 6 hours, chus showing a longer Fever is self-limiting and rarely poses severe consequences ‘unless the oral temperature is greater than 106°E (41.1°C), > The main treatment goal of fever iso eliminate the under- lying cause as well a o alleviate the associated discomfort > Fever should be confirmed only by using a thermometer and appropriate measuremient techniques, > Rectal tempersture measurement is the most accurate methods however, oral, tympanic, and temporal measure- iments are aso accurate iftaken appropriately Patients should be referred for father evaluation iftheir ree- tal temperature or its equivalene is greater than 104°F (40°C), they have a history of febrile seizures, they have comorbid conditions compromising their health, or they ate younger than 6months with a temperature exceeding 101°F (38.3°C), > Sponge baths using topical isopropyl or ethyl aleohol to reduce fever should be discouraged, > Refernal for further medical evaluation is appropriate to de- tect an underlying cause if 3 days of self-tearment are not succes > Clinicians should counsel patents on the proper use of non= rserpon ane gens toni reaon enor and Y REFERENCES 1. Naina Anmbulitry Mel Cave Survey; 2002 Samay, Adve data fo il ad eh tats. Washington. DC: US Department of Health 2nd Human Services. ADR No. M.Avaable a: p/w. gov/ chat add pa La acesed Ange 3, 208, Rehm KP Fever in nas and chile, Cr Opin Pat, 2001513:83-8 CCheny DK, Woodell DA, Rechsteiner EA. Nina! Anay Mata {Care Sune: 200 Summary. Ado dat om vital and hel ttt ysewvile Mi: National entrfor Heh Sais 2017 ADR. No 387 Aral a hp are po /nch/ data BST pl Last ccd Auge 3, 2008. Halon LL, Bernanl DW. Management of deus ince’ hyperemia. (Car Opie Pes, 2004162115, Mackowk DA. Concepes of fever. Ae ner Med 1998:158:1870-81 Dinarello CA, Gelfind JA. Fever and hyperthermia. In: Kaper DL Brault , Fact AS, a, Hai’ Pipes of hoa Medi tah ed. New York: McGraw Hil Ie; 2005: 108 [Nowtan DC. Fevers the eel. Cli Ife Dis. 2000;31:148-51 DiPio JT, Ownby DR, Schevsaan LS, Allg and pedo dag rexcions In DiProJT, Tabet RL. Yee GC, ta, ee: Papas A ates Apa ee. New York: MeGraw-HI Ie 20951399 9, Kumar KL, Reale JB Dag fever. West J Med. 19861487535, 10, Johnson DH, Cunha BA. Drag fever. In Dis Ci Nort An. 199610 e591 1 Gun. Eo Ca, Dried yp Ce 12, Velammor V, Newroepic malignant synome: recognition, prevention, and management. Dg Sof 199819-73-82. A. Netea MG, Kaifeng BJ, Van der Meer JW. Circulating cytokines a meditrs of Fever Cit Infor Di. 200031S178-84, 1S. ELRadhi AS, Bury W. Thermeometry in pacditic practice. Ank Dis Child. 2006, 91-351-6, 16, Rabinowier RP. Cookson ST, Wancran 8S, ta Ee of anatomic Ste, ol mulation, and body poston on estimates of bay temperate ‘Ae no Mel 19361560777-80 17, US Environmental Protection Ageny. Stat an Local Merry Cale ton eceling/ Exchange Programs. Available at p97 ep. g007| ‘puonver/harwate/merurycollec htm Lt scene Aga 3, 2008 18 Goldman LR, Shannon MW; Committee on Environmental Heh “Technical Report: mercury in the envionment: pico for dia teins. Pas, 2001 1080}:197-205 19, Thennomter comparison. Pasi Ltr Pere Ler 207.2310) 20, ProwS. Quin B). The per themometer comparion ofsepeaingsal ‘vith rca tempetataresin infin and young chien. hPa Ase Mb, W97s1S1SS1-4 21, Caltnon D. Dect everin young rai of perceives, pact Ser, and temporal artery trp in nis Younger than SmontisoF ge Peli ey Cae, 20085192103, 22 Robinson J, Sel RF, Spady DW, ct al Comparison of exophagel r= ‘al airy, blader, tympanic, and pulmonary aren temperate in shildenJ Peay, 1998:139555-6, 23. Greenes DS. Fesher GR. When body temperature changes, does rea terperacare ag? J Pein 2004 4424-6 24. Bemardo IM Henker R, O'Connor J. Terspertre meanurcment i pedarceauma paisa companion of hemometry and measurement Toutes, Emer Ni, 1999,25827-9 25, Wika Beco Waid, eta. A compari of the se of nally andrecl thermometer] Phd Nie IB 26. Cig V, Lancater GA, Taylor, ea. lnared ea dhemomety om ped with rect hermomeny in chen: a tematic review. Lac 22360 5-9, 27. Vamey SM, Manthey DE, Culpepper VE, et. A comparion of or ‘yempanic, and rectal temperate sesame in the elec J Ene 28 Jea-Mary MB, cari Shaw) “Masculoskeletal pain arises from the muscles, Bones, joints, and connective tisue, Similar to other types of pain phenomena, ‘musculoskeletal pain ean be idiopathic, iatrogenic, or related t0 injury. The development of musculoskeletal pain can be acute such as acute spore injuries (eg, tendonitis, sprains, and strains) ‘or chronic such as pain from stable degenerative joint disease oF ‘osteoarthritis. Unfortunately, musculoskeletal pain isabo used 0 describe regional discomfort arising from any soft tisue source Gnchiding the skin) which leads to confision among clinicians and in che medical literature. Table 7-1 describes these and other types of musculoskeletal complains/disorden, Use of nonprescription analgesics and external counter- irvitans remains high, with more than $2 billion spent per year in che United States on these nonpreseription remedies,” In addition, nearly 80% of adults admit to taking a pain reliever at least once a week, with many taking these products inappropri- ately. This high medication use and misuse present significant challenges for providers. Ideally, patient experiencing pain will ask a health care provider to assis in selecting a nonprescription ‘or prescription product. Health care providers need to understand ‘the types of pain for which patients are seeking treatment and 10 ‘communicate effectively with patients to better understand the nature ofa specific patients pain complaint. They must also be ready to provide reasonable recommendations fr either meatment ‘or further evaluation, ‘Musculoskeletal complains result ina significant amount of | lose work days, work limitations, and lossof employment, andare believed to be the greatest contributors co the economic burden, (of chronic pain; musculoskeletal complaints are estimated 0 cost the US. economy more than $60 billion annualy.* Backache and, ‘osteoarthritis ae highly prevalent pain complaints with approxi- ‘mately one-half ofthe USS, population older than 70 years hav- ing osteoarthritis” Approximately one-tenth of che working. ‘population ising treated for arthritis with prescription medica tions, whereas many choose to sel-treat and go unreported” Hence, the incidence and prevalence of reported skeletal muscle injuries may be underestimated. CHAPTER Eric Wright Pathophysiology of Musculoskeletal Injuries and Disorders ‘The musculoskeletal system includes the muscles, endoms,lig- aments, cartilage, and bones (Figure 7-1). Muscles are attached tobones by tendons, and ligaments connect bone to bone. Under. normal conditions, endons and ligaments have limited ability to stretch and twist, Because of their tensile strength, tendons and ligaments rarely rupeure unless subjected to intense forces, but they may become damaged when hyperextended or over- used, Synovial bursae are fluid-filled scs located beeween joint spaces to provide lubrication and cushioning, ‘Cartilage functions as protective pads between bones in Joints and in the vertebral column. Skeleal, or striated muscle, ‘is composed of cells (myocytes) in which «wo constituents (actin and myosin) are primarily responsible for contraction, Muscle ‘contraction also involves several electrolytes within the mus- cle tissue, including calcium and potassium. Pain receptors are located in skeletal muscle and the overlying fascia and can be stimulated as a result of overuse or injury to the muscle or sur- rounding structures, Somatic pain occurs when pain impulses are transmitted from peripheral nociceptors to the central nervous system (CNS) by nerve fibers. Common sites of origin of somatic pain are mus- cles, fiscia, bones, and nerves. Somatic pain is most commonly myofascial as in a muscle strain, or musculoskeletal, as in arthri- tis. Trigger points, which can occur following injury or immo- bility of the affected tisues, cause a reproducible, referred pain pattern when pressure is applied. (See Chapter 5 for discussion of transduction, transmission, perception, and modulation of pain.) Mechanoreceptors and chemoreceptors mediate muscle pain. These nerve endings are heterogeneous in that only a sin- ile chemical can stimulate some endings, whereas a variety of chemical, mechanical, and dhermal triggers can stimulate othe. Ischemic musele pain is caused by intramuscular pressure dur- ing activity that reduces blood supply to the muscle. Normally this effece disappears within seconds of muscle_relaxation. Ischemic muscle pain lasting for longer periods is believed to be mediated by the actions of histamine, acetylcholine, serotonin, bradykinin, adenosine, and potassium. Erythema (ednes), edema, and tendemess(hypergesa) at the alfeted ste characterize the inflammatory response, which develops through participation of multiple mediators, including. hisamine, bradykinin, serotonin, leukotrienes, and prostaglandins of the E series. Opioid receptors in peripheral dssues may play a96 SECTION 11 _ Pain and Fever Disorders Myofascial pain: pain originating in the fascia [Musculoskeletal pain: pain originating in the muscle |Myalgia: generalized muscle pain Fibromyalgia: chronic pain syndrome characterized by difuse mus cle and joint pain, joint stifness, fatigue, and sleep disturbances Strain: injury to a muscle or tendon caused by overextension Sprain injury to a ligament caused by joint overextension Muscle spasm: involuntary contraction of muscle ‘Muscle cramp: prolonged muscle spasm that produces painful sensations role inthe inflammatory response and may exert antihyperalgsic activi.” Because pain and inflammation inerease prostaglandin production, drugs that inhibit peripheral prostaglandin production (e., nonsteroidal ani-inflammatory drugs [NSAIDs) reduce the transmission of pain impulses ftom the periphery to the CNS, “Muscle injuries can be categorized as strains (ee subsequent text), contusions caused by blunt trauma, and delayed onset muscle sorenes (eg, overexertion). ‘Onereseion oF repeated acted entre muse ontaton is sociated with delayed-onset (8 hours oF more) muscle soreness, ‘which ean las for days, usually peaking at 24 to 48 hours, This pain reflects muscle damage thar was presumably initiated by force gen= crated in the muscle fibers, andi thought be induced by inflam ‘mation, acidoss, muscle spasms, and/or microesions, Prolonged tonic contraction produced by exercise, tension, or poor posture, and by body mechanics can ako produce muscle pain. _Myalia can also result from systemic infections (eg, influ cenza, coxsackievirus, measles, and other illnesses), chronic dis- ssitis and tendonitis. These two painful juries, which often result from overuse of a int or tendon, can cause inflammation, ling, and tenderness in the injured area. urce: Reprinted with permission from Pharm. January 1995;20(1),) orders (e.g, fibromyalgia and polymyalgia rheumatica), and, medications (e.g., some cholesterol-lowering agents such 3s, statins)" Abuse of alcohol may precipitate acute alcoholic ‘myopathy. Bone and muscle pain (ftom osteomalacia) may also ‘occur, resulting fiom a diet deficient in vitamin D. ‘Tendonitis isthe inflammation of a tendon, which results fiom acute injury of from chronic overuse of a body part (Fig ture 7-1), An example of an overuse injury is carpal rane syn drome, a condition characterized by tingling or numbness of the fine digits of the hand caused by repetitive use of the hands and \wriss, Tendon sheaths become inflamed and constrict the median nerve as it passes through a narrow channel between the wrist bones. In industry, fictors such as poorly designed equipment, awkward working positions, lack of job variation, long work, hours, and inadequate res breaks contribute to is development In sports-related overuse injuries, contributing factors for ten dlonits can include increased age, poor technique, improper con- dlitioning, exercise of prolonged intensity or duration, and pootly designed equipment for specific activities (€-., poor cushioning, of athletic shoes). Tendons ean become strained when their seretch capacity is exceeded, sch asin a hyperextension injury ‘of an arm or leg. Eccentric contraction of the muscle while the ‘muscle is lengthening causes the injury. Lay, luoroquinolone antimicrobials have been suspected in the development of wen= ddonitis and tendon rupture, and these medications carry a boxed. \waming. Patients older than 60 years who are taking steroids, or have had heart lung, orkidney transplantation are at greater risk? Burs sa common cause of localized pain, tendemess, and swelling, which is worsened by any movement ofthe structure adacent to the burs (Figure 7-1). Burts generally results from either an acute injury to the joint or over-repetitive joint action, ‘When pain is accompanied by presence ofa puncture site (pos bly from intra-articular injection), an adjacent source of infection, fr severe inflammation, an infectious cause should be suspected, and ruled out before recommending sel treatment. Sprains are che most common problem with ligaments Sprains are characterized by grade, with grade I sprains resulting fiom excessive stretching, grade I sprains froma partial tear, and ‘grade III sprains involving a complete tea ofthe tissue, The teat ‘oF rupcure ofa ligament is more common than that ofa tendon, Examples of ligament sprains include inversion of the ankle (curning inward at an extreme angle) and tearing of the ante~ ror eruciate ligament ofthe knce during rotation or ewisting, motions. Anterior cruciate ligament teats are relatively common injuries in sports such as basketball, volleyball, football, tennis, and skiing, in which knees ate involved in both propelling and, pivoting the body. ‘Law back pain isthe fifth most likely reason for a physi- cian visits che lifetime prevalence of developing low back pain approaches B0%."” Main risk factors forthe development of low. back pain include sedentary lifestyle (particularly one distupted, by bursts of activity), as well as poor posture, improper shoes, excessive body weight, poor mattresses and sleeping posture, and improper technique in lifting heavy objects, Akhhough most patients recover within afew days to a few weeks with comser- vtive treatment, low back pain is likely to recur ifthe intial episode of pain is severe, and if the patient has had multiple prior episodes." (Other causes of low back pain include congenital anom= alles, osteoarthres, vertebral fractures and compressions, spinal tuberculosis, and referred pain from diseased kidneys, pancreas, liver, or prose. Pain from arthritis has been attributed to a number of dif ferent sources including joint instability, increased presure in the‘Musculoskeletal Injuries and Disorders. CHAPTER 7 97 spaces between bones, inflammatory synovitis, periarticular involvement (e.g, busts), muscle atrophy, periosteal elevation, fibromyalgia, pain amplification, and central pain mechanisms, Even in the same individual, che pain may arise from different sources at any given time. Osteoarthritis is characterized by a gradual softening and destruction ofthe cartilage between bones. Cartilage and bone are destroyed in the joint spaces and regenerated, eausing a rearrangement ofthe synovial architecture. Ofien referred t0 as “degenerative joint disease,” osteoarthritis is caused by genet ‘metabolic, and environmental fictors, Heavy physical activity, repetitive movement, and lifting of heavy weights may ageri~ vate this condition, whereas light-to-moderate activity does not and is generally helpfl.= Clinical Presentation of Musculoskeletal Injuries and Disorders Table 7-2 lists many of the presenting signs and symptoms of musculoskeleul disorders and aso diferentes other fc~ tors. Paina common symptom among dhe musculoskele- tl disorders In adtion tothe pin induced by a sprain, ptints Rave soriale degrees of join inetion. With fanesonl imitations, the injury s most likely tobe a grade Ifo grade tt spain and needs proper workup to rule ott a ature or tea. If visibly ‘deformed, jones probably mpaured or fatared and requires tmergency anise Patents with carpal tunnel syndrome ofen experience sense of heat or co a sense that their hands are swollen when they ae not, weakness, and a tendency to deop ings. Symp~ toms penise daring sleep and even when the hand is noe being ted; a characteristic that can be used to distinguish this dis order fom others The pain of ostcourthris des not comeate directly with the degre of joint damage. Pain often referred, and proximal ‘muscles could be involved ifa peron with estoarhrits guards the affected joint by changing the gait to redace discomfort The pain eatsed by chronic oxeoarthntisofen mits the patients activities of daily living (ADLS) (eg, anable ro gp containers fr walle more than ashore dance), Ie is unclear which joint seructres ae responsible for the pan ad ciscomfort, but che pain has variably been ascribed to derangements of bone, ct~ tage, mace, connective tse, and nerves supplying the affected joint) Pain and sightnes in the low back are ao often caused by posture, mosle suppor, and degenerative changes, and often Tinta patent’ aby to bend, move, st oF walk, Low back ymin can be neuropathic in nature and involve the selatie nere, ‘sing sharp refered pain into one or both of the paien’'s eps. Stans and sympoms that preclade self-teatment ofthese disorders ae listed in Figore 7 ‘Complications of untreated pain-inducing injures inelude farther disue damage and, n advanced anhrits, bone and car~ tle remodeling The mostserious complication of poorly man- {aged pain is cbity and los of fncton, Pain is asoiated with ‘giant imitations inching rducon in ADL, lx of work tine, and physical impairments such as insomnia, Compliccons may abo aise if the etiology’ of the pains misdiagnosed oF judged, eis important to look for warning signs Gee exchasons forself-reatmen in Figure 7-2) hat indicate the pan ennot be ‘managed with nonprescription analgesics Treatment of Musculoskeletal Injuries and Disorders ‘Acute pain isthe body’s alarm system; it signals injury by rauma, disease, muscle spasms, or inflammation. Chronic pain, con- versely, may or may not be indicative of injury and requires pri- mary care provider’ assessment before treatment is initiated, Treatment Goals ‘Treatment of the patient with musculoskeletal complains encom- passes many different goals, including (1) decreasing the subjective intensity (everity) and duration of the pain; 2) restoring fune- tion of the affected area; (3) preventing reinjury and disability (e,, improve ADLs); and (4) preventing acute pain from becom 1g chronic persistent pai. General Treatment Approach Paticnts with musculoskeletal injuries present with similar symp- toms, especially pain and swelling ofthe affected area, These con- lions have similar self-treatment approaches. Nonpharmacologic therapy consisting of res, ce, compression, and elevation (RICE) along with nonprescription analgesics (ie,, NSAIDs oF acetamin~ ‘ophen) and/or external analgesics during the fist 1 to 3 days fol- Jowing injury are helpfl. Before eaument can be recommended, however, the patient should be careilly screened to ensure appro~ priatenes of sel-treatment. The algorithm in Figure 7-2 presents | stepwise approach to self-management of pain asociated with these complaints for patients who do not meet the criteria for exclusion for sear. Patients with acute low back pain are candidates for sel treatment, Chronic low back pain (ic, lasting more than 6-7 weeks) requires medical evaluation before initiating ther- apy. Management of acute back pain includes rest and ice, non= prescripcion onl analgesics and nonprescription topical analgesics. Approaches to chronic low back pain also include therapeutic interventions such as hea therapy, masage with traction (contra- indicated for pregnant women and people with osteoporosis, ‘umor, or spine infection) and, most importantly, mobiliza~ tion with exercise (a program of techniques and exercises 0 restore back mechanies and movement). Chiropractic manip- ulation and acupunceare (ofien with electrical stimulation) are also commonly used for the treatment of back pain, with ‘mixed resales" Rheumatoid arthritis, gouty arthritis, Lyme arthritis, and ‘osteoarthritis all cause arthritic pain, but only the pain of osteo- arthritis is approved for se-trearment after an initial medical diagnosis. The general treatment approach includes appropriate lifestyle changes (including physical therapy and weight los) and systemic therapy with standard doses of acetaminophen or lower-dose NSAIDs, with or without topical therapy."> Nonpharmacologic Therapy Injury from playing sports or exercising is preventable by warm~ ing up and stretching muscles before physical activity, ensuring. proper hydration, and not exercising to the point of exhaustion. Suetching must be done cautiously, without bouncing, o avoid ‘muscle strain, For muscle cramps, stretching and massaging the affected area immediately followed by rest, or at least reduced activity, will loosen the muscle. For electrolyte depletion, appropriate oral supplementation of wasted electrolytes can be8 SECTION 11 Poin and Fever Disorders Myalgia Tendonitis Bursitis Sprain Strain Osteoarthritis Location Muscles of Tendon loca- Inflammation ofthe Stretching ortear- Hyperextension _Weight-bearng joins, ‘the body tions around bursae within ingofaligament "of amuscle or ‘knees, hip, low back, joint areas Joints; common within joint tendon hands locations include knee, shoulder, big toe Signs Possible Warmth, Warmth, edema, Swelling, bruising Swelling, bruising Noninflammatory joints, swelling ‘erythema, and narrowing of joint (ere) possible crepitus space, restructuring of bone and canilage {esuting in joint ‘deformities, possible jot swelling ‘symptoms Dull, constant _—Mildto-severe Constant pain that Initial severe pain Initial severe pain ul joint pain relieved ache (sharp ppaingener- worsens with followed by ain, with continued ——_—by rest, joint snes Pain relatively ally occuring movement or partculaly wth painupon move: <20-30 minutes, local Fare); weakness afteruse;loss application of Joint use;fender- ment and at ized symptoms to joint andtatigue of ofrange of external pressure ness; reduction rest, muscle muscles also ‘motion over the joint injointstabilty weakness, loss common and functon | (of some function Onset Depending Often gradual, Acute with injuns Acute wth injury Acute with injury _Insidfous development on cause ‘butcan recurs with pro ‘over years (ie, trama= develop Cepitant use of acute, but suddenly joint ‘rug-induced insidious) Etiology Trauma, overuse, Trauma, over- Trauma and exces- Hyperextension of Excessive svetch Degeneration of joint infection, dug- use, druge sive wearuse: jontligament ‘of muscle or space from genetic, and aleohot- induced, septic busts tendon metabolic, and envi- induced inflammatory (most frequently ronmental factors diseases preceded by trauma and) caused by Staphylococcus ‘2ureus) present ing with fever ‘and acute painful swoling Exacerbating Factors Contraction of Movement of Movernent of Movement of Use of affected Obesity, lack of activity, ‘muscle affectedjoint affected ints affected joint muscle oF heavy physical activity, tendon repetitve movement, traumaMyalgia Tendonitis Bursitis Sprain Strain Osteoarthritis Modifying Factors Eliminate cause; Eliminate Jeintrestimmobi- RICE; stretching: RICE; stretching; Continuous exercise Use stretching, cause; use of Ization, topical -—=swse of protecive use of protective fightto-moderate rest, heat, stretching, analgesics, 9s-—wraps(eg. ankle wraps topical activity), weightloss, topical anal rest, ice, Temicanalgesics tape, knee brace, countereitants, analgesic medication, ‘gesics Sys heat, topical canal, topical systemic topical pain reliovers Temic analgesics analgesics, counterintants, analgesics systemic systemic analgesics analgesics Key: RICE, rest, ice, compression, elevation (see Table 7-3). Pion with compat of pain 1 Moderateto-avere pain (pain sexe >) 1 Pain that ate >2 woke 1 Pain that continues >7 days ater veatment ¥ Seatac eee Patarbaiaaecaa pin | [al PeMe tara fates erent Ghranmescatorninay cf | _& Aesompnyng pes, vrming, ve oes of tec econ ce decnder rmesetones ay pevtsusest | _ Valdas skrrl ovement wes any bor epee ari Imeacrenserorudex Osan, | | 8 Thames gener maa an sag iy 1 aaron TON moe * Minimum age fo so vais wih products, Use with easton and for shortest weatment pated posse in chidren £18 year of age. ¥ Exchnons for sattreatment Lves—>[ Wedicareferal ¥ Pain rom overenerion, cr muscle | yg 9 Dignan ofaaacantans? ENO oe T T Yes ‘ea + M makeictpica]) [aman Soe any Sageertpctincyesc | | Seopereathe, Lgl Penreitaiiicon Lg) serpy oad pea Eine iba ee * + Comma Commies] Fampentoreed pres] Seaestes | Lia Raeatareer Srebe & - ¥ ¥ eae Taree Prostrate Soman oe GIGV— > Selt-care of musculoskeletal injuries and disorders. Key: ADR, adverse drug reaction; APAP, acetaminophen; OTC, over-the-counter; RICE, rest, ice, compression, elevation. (Adapted from Sel-care of self-limited in. In: Albrant DH, ed. The American Pharmaceutical Association Drug Treatment Protocols. 2nd ed. fashington, DC: American Pharmaceutical Association; 2001:424-5})100 SECTION 11 _ Pain and Fever Disorders sed, withthe selection of Mud containing potassium, sodium, and magnesium, Posture and the use of ergonomic controls (such asa chair with back support or ergonomic keyboard) improve function and reduce pain, Heel hits and better-fitting shoes are recom ‘mended for patients with Achilles tendonitis, RICE therapy promotes healing, and helps reduce swelling and inflammation associated with muscle and joine injuries (Table 7-3), lee should ‘not be applied for mote than 15 minutes, because excessive icing causes considerable vasoconstriction and reduces vascular clear~ ance of inflammatory mediators from the damaged area Ice ther- ay should be used as close as possible to the time of injury and applied three to four times a day uni the swelling decreases, gen- erally 12 co 24 hours, but may be continued for 48 0 72 hours for more severe injuries (¢., ankle sprains). In addition, postexercise dng is offen appropriate to reduce the ikelhood of inflammation and to reduce pain. le, as well a heat, at temperatures outside the skin's threshold for tolerance can be damaging and can result i biisering or burning; therefore, nether therapy should be applied srecly to the skin, Although the purchase of produce designed to deliver ice therapy is not needed for effective we, many prod- ucts are available for purchase, which ease the application. Com pression and elevation also assist in reducing the swelling and pain, and should be instituted whenever possible. Heat therapy is an alternative for patients who develop pain of noninlammatory nature. thas been studied inthe treatment ' Rest the injured area after injury and continue until pains ‘reduced (generally 1-2 day) Slings, splits, or crutches can bbe used ifnecessay. 1 Apply ice a8 s00n a8 possible tothe injured area in 10-t0 15-minute increments, 3-4 times a day. Continue the ice pack therapy for 1-3 days, depending on the severity of injury 1 Apply compression tothe injured area with an elastic support (oF an elasticized bandage as follows: “Choose the appropriate size bandage forth inured body part If prefered, purchase a product specially designed for the injured body par. Unwind about 12-18 inches of bandage a atime and allow the bandage to relax. ice is also being applied tothe injured area, soak the ‘bandage in water to aid the transfer of cold Wap the injured area by overlapping the previous layer of ‘bandage by about one-third to one-half ts width rap the point most distal from the injury. For example, if the ankle i injured, begin wrapping just above the toes. Decrease the tightness of the bandage as you continue to ‘wrap. H the bandage fee's tight or uncomfortable or circ lation isimpaied, remove the compression bandage and rewrap it, Cald tes or swollen fingers would indicate that the bandage is too tight. Alter using the bandage, wash it in lukewarm, soapy water; ‘d9 not scrub it Rinse the Bandage thoroughly and alow to air dry ona flat sutace. Rollup the bandage to provent wrinkles and stort ina cool, dry place. Do not iran the bandage to remove wrinkles 1 Elevate the injured area at or above the level of the heart 2-3 hours a day to decrease swelling and to relieve pain Key: RICE, rest, ic, compression, elevation, ‘of acute low back pain (<4 weeks’ duration) with favorable effects." Although its mechanism of action is not fully uncer~ stood, heat may help to reduce pain by increasing blood flow. Heat is applied for 15 go 20 minutes, dhree to four times a day. Heat should not be applied to recently injured (<48 hours) or inflamed areas, because it will intensify vasodilation and exacer- bate vascularleskage and tisue damage. Furthermore, heat should, not be used with other topial agents or over broken skin, Heat should be applied tothe affected area inthe form of a warm wet, ‘compress, heating pad, or hot-water bottle. Ease of use favors newer heat-generating adhesive products (eg, ThermaCare), ‘which can be wor on the affected area up t0 8 hours, Product formulations are now widely available for the area affected, (ies, adhesive heat patches for low back pain). Heating devices should nor be used on areas of kin with decreased sensation; this, practice can lead toa skin bu, Although not generally associated with many side effects, at least one formulation of heat patches caused first-, second and third-degree burs along with skin intation, leading to product recall." Patients should be advised to remove the patch immedi- ately ifthey have any pain or discomfort, itching, or burning. Heat wraps should be worn over a ayer of clothing in patients ‘olde than 85 years and should not be used during seep. Physical and rehabilitative therapies have been used to teat acute pain ftom spor injuries and go teat chronic pain, Physical therapy can assist in building up supporting muscle structures, sich as the abdominal muscles that support the lower back. Phys ical therapy is often supplemented with deep tissue heating with ultrasound, which has demonserated some positive resus! Chronic musce pain often requires structured physical ther= apy to isolate and stretch affected muscles. Although it may be appropriate to rest an injured muscle for afew days, failure 10 mobilize the area once the acute injury begins to heal will often result in che muscle becoming tight, weak, and overly contracted (guarded). Once guarding occurs, patients can develop a tight band of muscle tissue. The tight bands are referred to as ttig- ‘ger points, Trigger points can arise in any muscle but are most ‘commonly seen in large musele groups. If musele pain becomes chronic, the painful area may require application of ice oF vapo- ‘coolant sprays, or injections, typically using local aneshetis (tig- ‘ger point injections [TPIs) to facilitate remobilization. Analgesics, and TPIs facltace physical eherapy for chronic muscle pain syn- sdromes; however, the medications are not curative, Pharmacologic Therapy Systemic Analgesics NSAIDs and acetaminophen are commonly used nonpreserip- ton analgesics, and are often employed in the intial treatment ‘of musculoskeletal injuries. Scheduled doses of nonprescription, strengths are instituted early in the couse of an injury, followed, by quick tapering of dose and interval 3s the injury improves, (generally in 1-3 days). Analgesic therapy should be limited to 7 days of self-care use, and patients should seek appropriate medical care if the condition continues beyond this period ‘or worsens during the course of treatment. (See Chapter 8 for dosages and properties of nonprescription analgesics) For the treatment of osteoarthritis of the hip and knee, aceeaminophen is the recommended first-line therapy versus NSAIDs, despite data suggesting that NSAIDs provide slightly improved pain relief" Responses to analgesics vary from patient to patient, and initial treatment recommendations are‘Musculoskeletal Injuries and Disorders. CHAPTER 7 made on the bass of dug safety rather than efficacy, while adjust~ ing drug cherapy according to patient response.!°> Chronie use ‘of NSAIDs leads to more severe and prevalent side effects such as, nephropathy, gstrointestinl ulcerations and bleeding, and the ‘potential for cardiac events2! Acetaminophen has a proven safety ‘record if given in che recommended! dasige, Chapter 5 describes, the safety of acetaminophen and NSAIDs in greater detail Topical Products Topical analgesics may have local analgesic, anesthetic, anti- pruritic, and/or counterirritane effects, Counteriritanes are approved specially for the topical treatment of minor aches and, pains of muscles and joints imple backache, arthritis pain, strains, bruises, and sprains). They are recommended as adjuncts 10 pharmacologic and nonpharmacologic therapy of musculoskele- tal injuries and disorders, ‘COUNTERIRRITANTS ‘Topical counerintants are topically applied to relieve pain. The difieence between counteriritants and other external analgesics (anesthetis, analgesics, and antiprurtis) is that the pain relief results more from nerve stimulation than depression,” Coun teritritation is the paradoxical pain-relieving effect achieved by. producing a less severe pain to counter a more intense one, On ‘the bass oftheir copial effets, counterimitans are clasified into four types (Table 7-4) Table 7-5 lss examples of commercially available products ‘Undoubtedly, the action of counterrrantsin relieving pain has psychological component. These agents may exerta placebo effect through pleasant odors, oF by the sensation of warmth or coolness they produce on the skin. Other factors, wich influ- ‘ence the intensity of response tothe countettritation, include the inane used, its concentration, the solvencin which itis solved, and the duration of is contact with the skin, Al regulations and labeling for topical counteriertants are ‘based on the detailed previous proposed rulemaking documents published in the Federal Register in 1979 and 1983." The US. Food and Drug Administration (FDA) has recognized the ingre~ 101 dents in Table 7-4 as safe and effective (Category I) counter- irritants for use in adults and in children ages 2 yeas and older.” Labels for counteriritants indicate that the product is to be used for “the temporary relief of minor aches and sprains ‘of muscles and joins.” In addition, the labeling recommenced by most of FDA's review panels includes claims for “simple backache, arthritis pain, stains, bruises, and sprains.”® Prod- uct labels may contain descriptors such 36 “external analgesic” or “topical” or “pain-relieving” cream, lotion, or ointment. However, these germs are not necessarily similar to the manu= facturer’s advertising claims.” The following sections deseribe the commonly used counterirtants currently available in the United States. Methyl Salicylate Methyl salicylate occurs naturally 2s ‘wintergreen oil or sweet birch oil; gaultheria oil and ceaberry oil are other names for the natural compound, In some areas of the United States, itis still referred to as "mountain tea.” Synthetic ‘methyl salicylate is prepared by the esterification of slieylic acid ‘with methyl alcohol, Methyl salicylate is usually combined with other ingredients with antipruritc or analgesic properties, such as menthol and/or camphor, ‘When applied co the skin at pain sites, methyl slic ‘other counterirttants produce a mild, local, inflammatory reac~ tion, which provides relief at another ste thats usually adjacent to, or underlying, the skin surface being treated. These induced sensations distract from the deep-seated pain in muscles, joints, and tendons. Pain is only as intense asi is perceived to be, and the perception of other sensations caused by the counterimritant or its application (¢g., massage, warmth, or redness) causes the suaferer to disregard the sensation of pain, The resule is that the patient's atention is diverted from the injored structure by the application of the counterirritant medication, Methyl salicylate, as a rubefacient, causes vasodilation of cutaneous vasculature, thereby producing reactive hyperemia; it 's hypothesized that this inerease in blood pooling and/or flow Js accompanied by an increase in localized skin temperature, which chen may exert a counterirritant effect, Because of this rubefacient action, methyl salicylate is responsible forthe “hot” action in many topical counterirritant products (Table 7-5). ea iritant Ex ip Group Mechanism of Action Ingredients Concentration (%) Frequency and Duration of Use A Rubefacients Ally isothioeyanate 05-50 For all countertants: Apply no more ‘Ammonia water 1025 ‘often than 3-4 times/day for up 0 Methyl salicylate 10-60 T days Turpentine ail 650 8 Produce cooling sensation Camphor 311 As above in group A Menthol 125-160 c (Cause vasodtlation Histamine dinydrachiorde 0.025-0.1 [As above in group A Methyl nicotinate 025-10 > Ince irtation without Capsicum 0.025-0.25 Acute pain: As above in group A rubefaction,areas Capsicum oleoresin. 0.025-0.25 Chronic pain: Apply 2-4 times/cy for potent as group Capsaicin 0.025-0.25 duration of pain often long-term use Ingredients ‘wth medical supenision) “Dosages approved for adults and for children 2 years and older. Source: Reference 22,102 SECTION 11 _ Pain and Fever Disorders Trade Name Primary Ingredients Menthol-Containing Products ‘Aspercreme Heat Pain Relieving Gel ‘Menthol 10% ley Hot Pain Relieving Gel Menthol 2.5% ley Hot Patch Menthal 59% ‘Camphor-Containing Products LeintFex Pain Relieving Cream Camphor 3.1% Capsaicin-Containing Products (Capzasn Arthritis Pain Relief No-Mess Applicator Capsaicin 0.15% (Cepzasi-HP Lotion/Crear Capsaicin 0.075% Zostrx Arh Pain Relief Cream Capsaicin 0.025% Zostic HP Cream Capsaicin 0.075% Histamine Dihydrochloride-Containing Products ‘Australian Dream Pain Relieving Arthritis Cream Trolamine Salicylate-Containing Products ‘Aspercreme Cream/Lotion ‘Sportscreme Deep Penetrating Pan Relieving Rub CreamvLation ‘Combination Products ‘ActivOn Topical Analgesic Ura Stength Artis ‘ActivOn Topical Analgesic Utra Stength Joint and Muscle Aathitis Hot Cream Bengay Uta Strength Pain Relieving Cream Flexall Ps Maximum Strength Pain Relieving Gel ley Hot Chil Stick Mentholatum Ointment Mentholatum Deep Heating Extra-Strength Pain Relieving Rub Cream Sloan's Liniment Tiger Balm Arthis Rub Cream Histamine dihydrochloride 025% Trolamine salicylate 10% Trolamine salicylate 10% Histamine dihydrochloride 0.025%, menthol 4.127% Histamine dihydrochloride 0.025%, menthol 4.127%, camphor 3.15% Methy/ salicylate 15%; menthol 10% Methy/ salicylate 30%; menthol 10%; camphor 4% ‘Menthol 18%; methyl salicylate 10%; camphor 3.1% Methy/ salicylate 20%; menthol 10% Camphor 9%; natural menthol 1.3% Meth salicylate 30%; menthol 8% Turpentine ol 47%; capsaicin 0.025% (rom capsicum olearesin) Camphor 11%, menthol 11% ‘The exact mechanism by which methyl salicylate produces iganalgesceffectisnot known, but in addition to the mechanisms described previously itis generally accepted that both central and peripheral inhibition of prostaglandin synthesis occurs, Studies on the rate and extent of percutaneous absomption of various com ‘mercially available methyl salicylate preparations show direct tis= sue penetration, rather than redistribution by the systemic blood supply, indicating a localized effect ofthe topical product." How- ever, systemic bioavailability increases with occlusive dressings, multiple applications, and application of the agents to different areas ofthe body in this order: plantar, heel, instep, forearm, and abdomen. At very low concentrations (0.04%), methyl salieylate is sed in oral preparations for its pleasant flavor and aroma, ‘The longer methyl salicylate or any counteriritant remains in contace with the skin, the longer is its duration of action. Lit- dle agreement exists on how long the counteritritants should remain in contact with the skin for optimal results; however, a practical guideline is that preparations should be applied no more than four times a day, Table 7-4 provides dosing information Localized reactions (i.e, skin irritation or rash) and sys~ temic reactions (i.e., salicylate toxicity) may occur with the use ‘of methyl salicylate. Strong irritation may cause local reactions such as erythema, blistering, neurotoxicity, or thermal hyper- algesia. There iso evidence thatthe risk of adverse reactions {© counterirrtants increases when the application site is lightly bandaged; however, an increased risk of iritation, redness, oF blistering does exist with tight bandaging or occlusive dress {ng ®=" Heating pads used in conjunction with counteriritanes ‘containing methyl salicylate have produced the clevated temper= ature, vasodilation, and occlusion necessary to greatly enhance percutaneous absorption of menthol and methyl salicylate, caus- {ng fll-thickness skin and muscle necrosis 2s wel as persistent interstitial nephritis” In addition, heat exposure and exercise after applying methyl salicylate have shown a threefold increase in systemic absorption of salicylate, which can lead to increases, in adverse systemic reactions.» Therefore, patients should avoid, sing heating pads or other heating devices in conjunction with, any external analgesics. Because percutaneous absorption can ‘occur, methyl sleylate should be avoided in children, as wells,‘Musculoskeletal Injuries and Disorders. CHAPTER 7 used with caution in individuals who are sensitive to aspirin ot Ihave severe asthma oF nasal polyps Although an FDA survey found that oral ingestion of | methyl salicylate formulated as ointments caused no deaths and thar few cases manifested severe symptoms.” regulations require the use of child-resistane containers for liquid preparations con- taining concentrations greater than 5%." Concomitant use of salicylate-containing extemal analgesics and maintenance warfarin cherapy hasbeen implicated in prolon ing prothrombin time.” Both methyl salicylate and trolamine salicylate were implicated. A later study showed that 11 patients tnad an abnormally clevated international normalized ratio afer significant use of topical methyl salicylate ointment." Chapter 5 describes other potential drug interactions related to systemically absorbed salicylates, Comphor Although camphor occurs naturally and is ‘obesined from the camphor tee, approximately three-fourths ‘of the camphor used is prepared synthetically. In concentrations of 0.1% to 3.0%, camphor depresses cura~ neous receptors and i used a a topical analgesic, anesthetic, and antiprurtic, In concentrations exceeding 3%, particularly when combined with other counterirritant ingredients, camphor stimulates the nerve endings in the skin and induces relief of | pain and discomfort by masking moderate-to-severe deeper visceral pain with a milder pain arising from the skin at the level of innervation. When applied vigorously, it produces a rubefacient reaction. CCamphor has the same indications as those for methyl salicylate. Table 7-4 provides dosing information, Concentrations higher than those recommended are not more effective and can cause more serious adverse reactions if accidentally ingested. The risk of toxicity relates to both the ‘concentration of camphor in the ingested product and the extent ‘of absorption of camphor into the body. CNS toxicity, expressed ‘primarily as conic-clonic seizures, isthe major toxicity nd begins to occur as early as 10 minutes following ingestion. In childre 5 ml of a 20% camphor liniment isa potentially lethal dose, and death resulting from respiratory depresion or complications of status epilepticus can occur. Accordingly, preparations with ‘camphor concentrations exceeding 11%, such as eamphorated, cil (camphor liniment), which ia solution of 20% camphor in cottonseed oil, are not considered safe for nonprescription use and have been removed from the market, However, even prod ‘ucts considered safe and effective (e.g, vapo-rubs) have been. associated with repors of serve adverse reactions with ingestion.” ‘Gastric hvage and activated charcoal administered shortly after ingestion have been used to avoid continued toxiciy.>* Emesis ‘will increase the risk of gastrointestinal toxicity an is generally, avoided. High doses of camphor can cause nausea, vomiting, coli, headache, dizziness, delirium, convulsion, coma, and death. Placing camphor into the nostrils of an infant may cause immediate respiratory collapse. In 1994, the American Academy ‘of Pediatrics Commitee on Drugs noted chat, although non- ‘prescription camphor-containing preparations cannot exceed, ‘concentrations of 119%, camphor toxicity continues, The acad= ‘emy advised parents to be aware of this potential danger and, recommended use of modalities that do not conta camphor.> Menthol Menthol is either prepared synthetically or ‘extracted from peppermint oil (which contains a 30%-50% ‘concentration of menthol). Menthol may be used safely in small 103 {quantities as alavoring agent and has found wide acceptance in candy, chewing gum, cigarettes, cough drops, toothpaste, nasal sprays, and liqueurs, concentrations es than 1%, menthol depresses cutaneous receptor response (Le, acts san anesthetic), whereas itstimulates response in concentrations greater than 1.25% (ie., acts as a counterrrtant) Recent studies have led to the identification of heat- and cold-senstive receptors within sensory neurons called transient receptor potential (TRP) cation channels. There are five other TRP receptors, the most notable of which is the vanilloid recep- tor, TRPVI; capsaicin activates this receptor, providing a hot sensation. Topically applied menthol activates the TR PMB men- thol receptor (discovered in 2002), triggering the sensation of cold.” The initial feeling of coolness is soon followed by a sensation of warmth, The resultant cold sensation travels along pathways similar to dhe somatic pain sensations from the affected ‘muscle oF joint, which distracts fiom the sensation of pain, Menthol, which has the same selftreatment indications 3s methyl salicylate, isaso used asa permeability enhancer to increase absorption of other topically administered medications,” In sinaller concentrations, menthol is commonly used for upper fes- piratory congestion and rhinitis (in cough drops and vapo-rubs). ‘Menthol may also provide symptomatic relief of dyspnea.” “Table 7-4 provides dosing information for menthol. The fatal dose in humans is approximately 2 grams, In acute studies, how= ever, menthol appears to be a substance of very low toxicity.” “Although of low occurrence, menthol use results in sensiti- zation in certain individual, causing symptoms such as urticaria, erythema, and other cutaneous lesions. “Menthol contraindicated in patents with hypersensitivity to the agent, Treatment should be discontinued ithe patient devel- (ops imation, rsh, buming, singing, swelling, or infection, Methy! Nicotine Although nicotinic acid is inactive top- ically, methyl nicotinate readily penetrates the cutaneous bar- ser. Vasodilation and elevation of skin temperature result fom very low concentrations, with higher penetration rates seen with hydrophilic mediums (i. ge). Studies have shown that indomethacin, ibuprofen, and aspirin significantly depress the skin’s vascular response to methyl nicotinae. Because these three drugs suppres prostaglandin biosynthesis, it was concluded that the vasodilator response to methyl nicotinate is mediated, atleast in pat, by prostaglandin biosynthesis. Methyl nicotinate has the same indications as methyl sali- cylate, Table 7-4 provides dosing information. Generalized vascular dilation can occur when methyl nico- sinate passes through the skin into the circulatory system, Susceptible persons who apply methyl nicotinate over large areas may experience a drop in blood pressure, a decrease in pube nate, and syncope caused by generalized vascular dilation, Capsicum Preparations Capsicum preparations (capsaicin, capsicum, and capsicum oleoresin) are derived from the fru of various species of plants of the nightshade family. Capsicum contains about 1.5% ofan iritating oleoresin, the major com- pponent of which is capsaicin (0.02%). Capsaicin is the major ppungene ingredient of hot (chil) pepper. ‘When applied to normal skin, capsaicin elicits a transient feeling of warmth through stimulation of the TRPVI recep~ tor.” More-concentrated solutions produce a sensation of barn ing pain. However, asa result of tachyphylaxis, this local effect diminishes with repeated applications, Capsicum preparations104 SECTION 11 _ Pain and Fever Disorders do not cause blistering or reddening of the skin, even in high concentrations, because they do not act on capillaries or other blood vessels. ‘The mechanism of action is thought to be directly related to capsticin’s effec on the depletion of substance P. This sub- stance is found in sow-conducting, unmyelinated type C n rons that innervate the dermis and epidermis, Iti released in the skin in esponse to endogenous (ress) and exogenous (trauma or injury) fictos. Tt appears that pruritic stimuli along, with pain impulses are conveyed co central processing centers by type C fiber in the skin, for which capsaicin as selective activity. Local application of capsaicin to the peripheral axon appears to deplete substance P fiom sensory neurons. The depletion occurs both peripherally and centrally, presumably a the result of impulse ini- ‘ation, When substance P is released, burning pain occurs but bates with repeated applications, This initial burning sensation oF the diminishing bur experienced with repeated applications can lead to adherence-relatd flures, and health cae providers should inform their patient's about these effects and the importance of continuing therapy, ‘Capsaicin has the same indications as those of methyl siey- late. Capsaicin is used to reduce the pain, but not the inflam- ‘mation, of rheumatoid arthritis and osteoarthritis, and i used in a wide varity of other pain disorders (e.g, posthempetic neural- si, psoriasis, and diabetic neuropathy). The efficacy of capssicin 's dificule to asses when compared with placebo, owing ro the dificult in blinding patients because ofthe recognition of bum= ing and stinging, For the treatment of musculoskeletal pain, cap- sticin 0.025% used for 4 weeks would improve pain by at leat 50% in one of every eight patients created. Improved efficacy is seen with 0.075% used in the treatment of neuropathic pain, suggesting dose-related effects. c menthol, capsaicin has been identified asa penetration enhancer. Concomitant administration with eapssicin enhances the penetration of mproxen through human kin, suggesting eff- cacy with combined therapy that i improved over that produced by either agent alone.*! However, this combination is only spec- tulaive, given that i has not been clinically studied ‘Table 7-4 lists dosing information for capsaicin. The opti~ ‘mal dose ofthis agent varies among patients, It appears that eff- cacy decreases and local discomfore increases when capsaicin is applied les often, because the drug’s duration of action is 4 60 6 hours, Pain relies usually noted within 14 days afer therapy has begun, but relief will occasionally be delayed by as much 3s +4t0 6 weeks, Notably, because capsicum lots vaty, the concen tration range for capsticin cannot be expressed asa percentage and must be calculated for each ls ‘Once capsaicin has begun to relieve pain, its use must con- tinue regularly three or four times a day to keep the pain from returning. If capsaicin treatment is stopped and the pain reeurns, treatment can be resumed. To reduce the likelihood of cap” saicin reaching topically sensitive area, such as mucous mem- branes, patiens should be instructed to use glove or phstic bag for application and wash their hands following use. ‘Overdose with use of capsuicin has not been reported, but tse of topical preparations with concentrations greater than 1% have been associated with neurotoxicity and hyperalgesia. Burning and stinging occur with the application of cap- saicin in 40% to 70% of patients. However, this effect generally sliminishes in intensity with continued use. Heapsiicin gets into the eyes oF on other sensitive areas ofthe ody, it will cause a burning sensation. Concentrations greater than 1.025% have also been associated with a cough.” ‘Use in patients with hypersensitivity 0 capsaicin is con- traindicated. The agent should be discontinued temporarily ifskin breaks down (weeping, red, and presence of small ulcer), and the agent should not be applied to wounds or damaged skin. Other Counterinitants Allyl isothiocyanate, ammonia ‘water, turpentine oil, and histamine dihydrochloride are also hssified as Category I counterititants by the FDA, but fewer ‘commercially available preparations contain these ingredients Most products that contain these ingredients also contain other topical analgesics, making any beneficial action o side effets ‘of these products indistinguishable from other ingredients In addition, very little evidence support the efficaciousness of these compounds. Allyl isothiocyanate, ammonia water, and turpentine oil are rubefacients, and should be expected to have effects similar to those of methyl salicylate, whereas histamine dihydrochloride causes vasodilation, similar in ation to methyl Category IIL ingredients (insufficient data are available to ‘establish safety and efficacy) include eucalyptus oil, crolamine salicylate, and topical NSAIDs, Despite this designation, several nonprescription products contain tolamine salicylate asthe pri- ‘mary ingredient (Table 7-5) Eucalyptus oil may produce some minor counteritrcant cffecs, but itis nor recommended for use as a counteritrtane because of inconclusive efficacy data. Eucalyptus is offen noted, as an inactive ingredient in some products because of its char- acteristic odor. Trolamine salicylate, although a salicylate sat, is not a ‘counteririant analgesic, Trolamine salicylate is absorbed through the skin and results in synovial fluid salicylate concentrations slightly below those of oral aspirin. The recommenced topical dosage of tolamsine salicylate for adults and for children 2 years and older isa 10% to 15% concentration applied to the affected, area not more than three or four times a day. Several studies led FDA to conclude that topical trolamine salicylate docs not show any significant benefit over placebo in the treatment of musculoskeletal pain, Reports published afer the review have shown limited effectiveness in alleviating neu- ralgia caused by unaccustomed strenuous exercise and muscle sorenes induced by a reproducible program of weight caning. Trolamine salicylate has also demonstrated improved playing ‘ime in musicians with localized pain in the arms, wrists, hands, and fingers, and improved pain and stiffness in patients with, ‘osteoarthritis ofthe hands. Trolamine salicylate isi avaiable ‘over the counter and may be most usefl to those patients who, do. not favor the localized iitation or the scent of Category I ‘Trolamine salicylate has the same drug interactions as other salicylates (see Chapter 5). Uses contraindicated in people with, renal insufficiency or with hypersensitivity to trolamine or salicylates. People who have liver disease, bypoprothtombine- mia (a deficiency of thrombin in the blood), or vitamin K defi- ciency, of who ate scheduled for sangery oF are chronic alcohol users should not use this agent. During use, the agent should not ‘contact the eyes or mucous membranes TOPICAL NSAIDS ‘Topical NSAIDs are not currently available for nonprescription, use in the United States, but FDA approved them for preserip- tion use in 2007 (Flector, 1.3% diclofenac epolamine patch) for the treatment of acute pain caused by stains, sprains, or contu~ sions. Topical NSAIDs have been used for years in Europe for‘Musculoskeletal Injuries and Disorders. CHAPTER 7 the treatment of musculoskeletal pain. They are not counter ievitants and presumably act locally in a manner analogous to their systemic mechanism of action. Their application on acute soft tisue strains and sprains, where the target tissue is situated, closer to the skin surfice, are reported to provide the benefits, ‘of oral NSAIDs with minimal systemic side effect Systematic reviews have concluded that topical NSAIDs are more effective than placebo in the treatment of musculo- skeletal pain for shore-term use, but they lose effectiveness beyond 2 weeks." A well-designed trial of 1.5% copical diclofenac solution applied four times a day demonstrated syimp- tomatic improvement in osteoarthritis of the knee following, 12 weeks of eeatment.** Dimethyl sulfoxide was used to help improve diclofenac penetration and also was present in the placebo, No significant gastrointestinal side effects were noted, in the tial, but localized dryness and rash were more prevalent in the ereatment group. Evidence to date suggests that topical NSAIDs provide effects on chronic knee pain comparable to those of systemic NSAIDS, with fewer systemic side effets.” ‘Combination Products ‘General guidelines for nonprescription drug.combination prod- ‘ucts state that Category active ingredients from the same ther peutic eategory should not ordinarily be combined, unles the ‘combination is deemed safer or more effective and has enhanced, patient acceptance or quality of formulation. Four separate ‘chemical and/or pharmacologic groups of counterirrtants pro- vide four qualitatively different types of initacion, Many mar= keted preparations aim for at lest two such effects when greater potency is desired. Table 7-4 lists che individual ingredients and, chssfes them according to their relative potency and acceptable ‘concentration ranges, Manuficturers may combine ative ingre- dents from one group of counteritrtants with one, two, oF thee other active ingredients, provided that each active ingre~ dient is from a different group, Its irrational to combine counterirritants with local anes- thetics, topical anipruriics or topical analgesies, Because these agents depres sensory cutaneous receptors, theit effects oppose the counterirritant stimulation of cutaneous sensory recep tors. It is also irrational to combine counterirrtants with skin protectants, because the protectants oppose and may nullify ‘counterirrtant effets, Preparation labels must lit the active ingredients, includ~ ing their concentrations, and must identify them by their of ally recognized, established names. In addition, manufictarers voluntarily lise ingredients on che bel. Many manuficeurers of ‘combination products lise only some of the active ingredients, ‘under the “active” heading, and many ofthe other pharmaco- logically viable products in the inactive ingredient section (8. BenGay Vanishing Scent Gel lists camphor, and Aspercreme Heat Pain Relieving Gel lss capsaicin under inactive ingredi~ cent), Although the concentrations of inactive ingredients are not listed, chey are generally below therapeutically determined amounts and ate added for reasons other than pain-relieving, ‘effects. The manner of use and the frequency of applications should also be indicated. Product Selection Guidelines ‘SPECIAL POPULATIONS. No significant variability in response has been noted among patients of diferene ages or racial backgrounds 105 Variability related to the minimum age of patients, how= ever, does exist in product labeling, According to the tentative final monograph published in the Federal Register in 1983, use of external analgesics, as labeled within the confines of the state- ‘ment, isto be avoided in children younger than 2 years. How- ever, most available products elect to label the minimum age 2s ‘older than 12 years, and some products (particulaely capsaicin products) list 18 years and younger, This more restricted label- ing is prudent considering the indications for the products and the potential for systemic absorption, but at chs time this label- 1g snot mandated by law. Practitioners should follow labeling structions forthe products used. Ifa produc i to be used in a child 18 years of age or younger, it should be used with caution and for the least amount of time necessary PATIENT FACTORS ‘The choice of treatment for acute pain syndromes and chronic conditions such as osteoarthritis is patient-dependent, In addi- tion to nonpharmacologic treatment, oral therapy is often ‘employed. One should considera patient's history, taking note of exclusions for sel-teatment, other medications the patient is taking, and any known allergies to medications. Topical therapy is used as an adjunct or substicute to oral therapy. Ifa counterirritant is selected, one with Category I ingredients should be recommended, Patients with precautions for the use of individual counteritriants should also be cautioned about the use of certain products, particularly combination products. Product concentrations are variable and, in general, the low- est effective dose should be recommended forthe shortest dura~ sion needed. PATIENT PREFERENCES Factors chat impact product selection include dosage form, ease of use, cost, and even odor of the preparation. Dosage forms available include solutions, liniments, gels, lotions, ointments, creams, and patches. Oleaginous preparations (ointments and oil based liniments) have increased absorption compared with solu- tions, gels lotions, and creams, but they are greasy and generally les acceptable to patients. The use of patches is becoming more popula, owing to their simple application and duration of action, but use ofa patch eliminates any benefit ofa therapeutie abbing action.’ With the exception of patches and solutions, topical products should be ribbed into the skin, Alcoholic liniments and gels may produce a response more intense than that of equal ‘Quantities in other preparations, and excessive rubbing should be avoided ro reduce the nsk of unpleasant buming sensations with these preparations, Additional information abour formulation characteristics is described elsewhere Complementary Therapies A variety of complementary therapies containing many diferent ‘compounds and ingredients are marketed for the management of pain, Is ditficule o find well-designed controlled clinical trials for many of these agents in humans, The most commonly used products are glacosamine, chondroitin, methyl-sufonyl-methane, and S-adenosyl-L-methionine, Additional products are sum ‘marized in Table 7-6. Additional information on these products and other complementary therapies such as massage, chiropractic care, and acupuncture have been described else- where and are discussed in greater detail in Chapters 54 and 55, respectively. 25106 SECTION 11 _ Pain and Fever Disorders Agent Uses Effectiveness Botanical Medicines (Scientific Name) Cat'sciaw (Uncaria tomentosa) OA, rheumatoid artis Other HIV, Gl lees, skin disorders, cancer (OA, tendonitis, appetite somulant IMyalgias(topicad Other (oral irtable bowel syndrome, dyspepsia Antiinflammatory, pain Devil's claw (Harpagophytum procumbens). Peppermint (Mentha piper) low bark (Salisp) Nonbotanical Natural Medicines Chondroitin sulfate oA Glucosamine sulfate oA Methylsulfonylmethane (MSM) Acute and chronic pain (arthritis, busts, tendonitis) S-Adenosyl-methionine (SAM) OA Bleeding risk with ant- ‘coaguants “Tras mainly in animals and in vitro ‘Anecdotal improvements GI higher dose headache, tinnitus Allergic reactions, respira- tory collapse ‘Short-term improvement in low back pain similar to 125 mg rofecoxb* Topical efficacy similar to menthol (Note: Herb contains menthol) Gastric ulceration, hyper sensitivity, bleeding, tinnitus, nausea and vomiting, skin rashes ‘Short-term improvement in fow back ain similar to 125 mg of rofecoxib Midi pin adravsen improvement in pin and eduction in ease progression in patients ine OnE Probable pain improvement and reduced diseate progression in patients with knee OA [No beneft in patients with hip OA Pain improvement similar to gh Mild Gi complains Nausea, dianhes, headache, pruritus, allergy symptoms “Multiple dose-dependent ‘Gi complaints Improvement in functional limitation Similar to NSAIDs, but delayed response and less pain improvement! Key: Gi, gastrointestinal; HV, human immunodeficiency disorder; NSAID, nonsteroidal antiinflammatory dug; OA, osteoarthts. Source: References 53-62. Assessment of Musculoskeletal Injuries and Disorders: A Case-Based Approach Routinely, the health care provider should inventory all past and present medications, including pain medications, and should note the patient's satisfaction with or preference for past treatments In addition, the health care provider should ask about aspects of the panel sory ta ete dele agin o et ‘ment of pai ‘Before an attempt is made ¢o treat a pain complaint, the health care provider should qualify and quantify the pain, Inquiry about the cause, duration, location, and severity of pain, 25 wells factors that relieve and exacerbate the pain, will help asses the pain, Chapter 2 outlines effective strategies for obtaining informa- tion fiom patients about specific complains. When a complaint ‘of pain is expressed by a patient, the health care provider should use effective communication to gather the needed information inclading symptoms, characteristics, history, onset, location, and aggravating and remitting factors. Using pain scale helps to quantify the intensity ofa patient's pain, With the numerical pain scale, the health care provider asks patients to rank the present pain on a scale of Oto 10, with ‘0 being no pain and 10 being the worst pain the patient can Imagine. Scores greater than 3 indicate the need for an inter- vention, as do any scores that increase 2 or more points on the To-poine scale. Initially, pain scores establish a baseline for pain before treatment. In addition, a high pain score can be used, to screen for patients who would be better served by seeking an appropriate medical evaluation, Pain scores also serve asa mea~ suring device for therapeutic outcomes. In general, nonprescrip- ‘ion medications are appropriate For numerical ratingscale scores, ‘of I to 3, These medications may also be appropriate for seores (of 4 or 5. Scores of 6 or higher indicate pain that requires med- ical referral. Other scales ae avaiable for pain rating in children (Faces Pain Scale), adolescens, people who do not speak English, and other special populations. A chronic painful condition presents different set of chal lenges. An observant health care provider should intervene with 4 patient who fRequently o regularly purchases aspirin, other NSAID products, or acetaminophen. If additional interviewing indicates an inadequately reated pain problem, addtional workup bbyan appropriate provider should be made. The workup will pre~ ‘vent unwanted long-term adverse consequences of drug therapy (€.g. renal impairment) as wellas assis the patient in receiving the appropriate care for the pain problem. Education should be ‘offered regarding the risks of inadequate treatment as well as the overuse of medications. (On the basis of the information collected, the health care provider can appropriately determine whether the patient may. sel treat or should be refered fr further evaluation, (Figure 7-2). Cases 7-1 and 7-2 are examples of the assessment of patients with musculoskeletal injures and disorders.‘Musculoskeletal Injuries and Disorders CHAPTER 7 107 CASE 7-1 eee enone Information Gathering 1. Gather essential information about the patient's symptoms, including 2. description of symptoms (i.e, nature, onset, duration, severty, associated symptoms) b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient's symptoms) ‘description of the patent’ efforts to relieve the symptoms 2, Gather essential patient history information: a. patients identity age, sex, height, and weight «patient's occupation patient's dietary habits «2. patients sleep habits {concurrent medical conditions, prescrip ‘on and nonpresciption medications, and dietary supplements, galleries h. history of other adverse reactions to medications 1. other (describe) ‘Assessment and Triage 43, Diferentiate patient’ signs/symptoms and correctly idetiy the patients primary prob lems (see Table 7-2. 4, Identify exclusions fr selttreatment (see Figure 7.2) 5. Formulate a comprehensive list ofthera- peutic alternatives forthe primary problem {to determine f riage to a medical practi- tion is requited and share this information with the patient. Plan 6, Select an optimal therapeutic alternative to address the patient’ problem, taking into account patent preferences. Peas Patient notes improved pain in knees following the addition of acetaminophen to her ostecarthritic regimen, but stil has some pain (1 month ago, rated waking pain as 5/10; now its 3/10) Walking long distances is dificult, Needs to rest at regular intervals. Patent notes that the acetaminophen she began taking seems to help, but it wears off midway ‘hrough the day. Patient started Tylenol anhriis 300mg 1 month earlier and takes it 1-2 times a day (usally inthe morning, sometimes at night. Margaret Butler 67-year-old female, $2 in, 17610 School bus river Patient eats out 3-4 times 2 week ata buffet-style restaurant, snacks while driving bus, and doesnot use tobacco or crnk alcohol Sleeps 6-8 hours a night with no complaints Osteoarthts of bilateral knees was diagnosed within the preceding year; medical management suggested by provider at this time; initated acetaminophen ¥ month eater Calcium carbonate 600 mg (elemental twice daly, multivitamin, and raniticine ‘occasionally for heartburn NKA None Patient has osteoanthits ofthe knee with improved symptoms on orl therapy. PCPs aware of pationt’s status, which has improved cecently with no alarming symptoms; self-treatment could be recommended. I, however, this patient's pain is worsening or does not improve with recommended treatment, the patent should discuss her care with her PCP. Options include: (1) Recommend nondiug measures (e.g, exercise, weight loss, use of cane). (2) Recommend adjustment of oral OTC analgesic to appropriate analgesic doses (ie., acetaminophen 1300 mg [arthritis formula] every 8 hours}. {3) Recommend adjunctive use ofa topical counteriritant. (4) Recommend altematve therapy (e.g. glucosamine). (5) Refer patient to PCP for further assessment and treatment. (6) Take no action, ‘The recommended therapy is exercise, rest, and weight loss, along with acetaminophen 1300 mg (arthritis formula) every 8 hours and a topical Counterirtant applied 2-4 times a day to the knees,108 SECTION 11 _ Pain and Fever Disorders CASE 7-1 (continued) cad 7. Describe the recommended therapeutic Exercise 3-5 times/naek by walking, biking, and/or stretching as tolerated, approach tothe patient. Exercise wil improve circulation; weight loss will reduce pressure onthe joint (Continue acetaminophen. Do not take any ther produc (prescription ar non- _rescrption) that conains acetaminophen, because you rsk taking too much [Scetaminaphen, Capsaicin or other topical counteriritant i an appropriate agent 10 se in conjunction with oral therapy a his ime. 8, Explain to the patient the rationale for Because you are experiencing some benefit wth acetaminophen, you should con: selecting the recommended therapeutic tinue this therapy, but take before the rug loses effectiveness to avoid recur ‘approach from the considered therapeutic _rence of pain, Despite the improvement with acetaminephen, you may continue to aktematives. have pain even when taking it. A topical countermitant isa useful adjunct to effec- tive ora therapy in osteoarthrit Patient Education 9. When recommending self-care with nonpre scription medications, convey accurate infor- ‘mation tothe patient 2. appropriate dose and frequency of (1) You should take the acetaminophen 1300 mg fathtis formula) every 8 hours. ‘sdminstration ‘You can skip the nighttime dose of acetaminophen f the pain dows not disrupt your sleep. (2) Apply small amount of capsaicin 0.025% gel to knees 3 times dally 'b. maximum number of days the therapy (Chronically administered acetaminophen (a nitally prescribed by the primary should be employed ‘ate prover) 2s wel as topical capsaicin ‘The response should be evaluated in 4 weeks. I helpful continue; fnot helpful, iscomtinve. product administration procedures ‘Apply three times a day; you can apply the gel at the same time you take aceta- "minophen. Be sure to wash hands before and after application, and do not use an ‘cclusive bandage. (See the box Patient Education for Musculoskeletal Injuries ‘and Disorders) d.expected time to onset of rl ‘Some improvement wil occur shortly after application, but maximal benefits wil take up to 6 weeks. @. degree of relief that canbe reasonably Osteoarthritis sa chronic condition for which acetaminophen and capsaicin asist expected with the perceived pain by the patient. You wll continue to sufr from the cond tion, but you should expec a noticeable reduction in pain along with improved ‘actos of daly ving 4. most common side effects (Capsaicin is expected to produce localized buring ike sensation; however, this ‘sensation i reduced within afew days with consistent application 3 times daly. ‘Contamination of mucous memibranes will produce significant ciscomfor because (ofthe intense burning sensation. 4. side effects that warrant mediealinterven- Localized razh See the box Patient Education for Musculoskeletal Disorders and tion should they occur Injures. hy patient options in the event that condition As noted, osteoarthritis is expected to persist. Pain improvement indicates contn- worsens or persists ‘ued therapy. No improvement or worsening of pain warrants further evaluation by ‘medical provider. 1. product storage requirements Keep out ofthe reach of children |: specific nondrug measures Reduced signs and symptoms, as well asa slowed progression of the disease, can 'be obtained with exercise and weightloss, and should be undertaken as tolerated. 10, Solicit follow-up questions from patient. ‘Should | use the cream only when the pain happens or all the time? 11, Answer patient's questions ‘This cream works better when itis applied 3-4 timesa day consistently, rather than only once day or as needed. You likely wll not receive the fll benefits of the therapy f you do not use the medication 3-4 times evary day. Therefore, ance itstarts working, you should continue applying it. key: NKA, no known allergies; OTC, over-the-counter; PCP, primary care provider.‘Musculoskeletal Injuries and Disorders. CHAPTER 7 109 CASE 7-2 eee enone Information Gathering 1. Gather essential information about the patient's symptoms, including 2. description of symptoms (i.e, nature, onset, duration, severty, associated symptoms) b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient's symptoms) «. description of the patent’ efforts to relieve the symptoms 2, Gather essential patient history information: a. patients identity age, sex, height, and weight patient's occupation patient's dietary habits patient's sleep habits concurrent medical conditions, prescip- tion and nonprescription medications, and dietary supplements galleries h history of other adverse reactions to mecications 1. other (describe) Assessment and Triage 3. Differentiate patient’ signs/symptoms and ‘coeclyidentiy the patients primary prob lems) (see Table 7-2. 4. Identify exclusions for sel-reatment (see Figure 7.2) 5, Formulate @ comprehensive list of therapeu- ticltematives fr the primary problem to determine if viage to a medical prectitioner isrequired, and share ths information with the patient. Plan 6, Select an optimal therapeutic alternative to address the patient's problem, taking into ‘account pationt preferences. Peas Patient presents with a slight gait disturbance and wants to purchase some regulacstrength aspirin and a heating patch, Patient notes that he was playing racquetball at the health lub earlier in the day and twisted his ankle. He says ‘that he had twisted it before, but this one “really hur." When he had his ankle sprain in the past, he was always able to walk shortly afterward without much difficulty, Upon inspection, the patient has a swollen right ankle thats tender tothe touch, but otherwise nat visibly deformed. The patent has a diminshed range of mation cof is ankle with tendemess upon manipulation. ‘The patient can stl walk, but its dificult and causes sharp pain in his ankle on a scale of 7/10. He applied an ice pack fr 10 minutes atthe gym after the sprain. He also ele- vated and rested the ankle at home for about an hour after the twist, which helped only itl, Jack Mouser 39-year-old male, 5f11 in, 214 lb Information technologist Eats a balanced diet during the week, but eats “whatever" on the weekends No problems sleeping; sleeps about 7 hous a night 'Mega-man multivitamin dally, occasional loratadine 10 mg daily for allergic hits (not aking curenty) KA None Last ankle sprain occurred 2 weeks earlier. He intended to purchase ankle braces ors acvties but has yet to do so. Patient’ presentation is consistent with an ankle spin Patient does have limitation for sel treatment, Because his mobility is lessened with the sprain, and he develops severe pain with movement Options include: (1) Refer patient to PCP fr futher assessment. (2) Recommend nonpharmacologic treatment e.g, RICE therapy) (8) Recommend oral nonprescription analgesic (2, acetaminophen, nonsalicylate NSAIDs, or salicylate). (4) Recommend topical ounteriitant (5) Fitpatient with crutches or cane. (6) Take no action, Refer patient to his primary care provider immeclately to rule out severe injury or ‘racture and to determine degree of sprain, Recommend RICE therapy (see Table 7-3). ‘Advise against asprin or heat therapy at his time.110 SECTION II Pain and Fever Disorders CASE 7-2 (continued) 7. Describe the recommended therapeutic approach tothe patient. 8, Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic aktematives. Patient Education 9. When recommending selcare with non- prescription medications and/or nendrug therapy, convey accurate information to the patient 8, appropriate dose and frequency of ‘sdminsration 'b. maximum number of days the therapy should be employed & product administration procedures d.expected time to onset of rlief «2. degree of relief that can be reasonably expected most common side effects 4g. side effects that warant medical nterven- tion should they occur h. patient options the event that condition ‘worsens or persists |. product storage requirements |. specific nondrug measures 10, Solicit follow-up questions from patient. 11. Answer patient's questions Patients with gait disturbances and severe pain upon movement indicate a poten- tially severe sprain and should not be advised to solf-treat ‘Your symptoms are consistent with an ankle spain, but unlike your previous sprains, this sprain is more severe and should be evaluated by your health care provider before self reatment. You should cal your health care provider tobe Seen as soon as possible. In the meantime, you should rest your ankle by elevating it on some pillows or in a recliner; then place ice over the ankle for 10-to 15-minute intervals about 4 times a day, and wrap the ankle in a bandage. You may take some non- prescription medication while wating to be seen by your provider. You may ‘choose from any ofthe nonprescription agents, but aspirin is nat recom ‘mended because ofits higher side effect prafle, Also, heat should be ‘voided until after the swelling subsides. lbuprofen 400 mg every 8 hours 2s needed for pain Patient should be seen by provider as soon as possible and should selt-veat only nti evaluated. “Take two 200 mg tablets every 8 hours as needed for pain rele. Take product with a litle food to reduce gastrointestinal initation, Improvement in pain is expacted within 30-60 minutes atertaking the medication ‘Your pain will not go away completely, but you should be able to walk with a litle less pain. Rest, ice application, and elevation are als helpful in this process of ‘reducing the pain. Consider catches ora cane to help with walking while the ‘ankle heals and gait etums to normal Minimal with short-term use, but some gastrointestinal complaints may present. ‘See the box Patient Education for Headache in Chapter. [A this time, this condition should be evaluated by the medical provider. Keep medication in container and away from children. See Table 73. ‘Should | purchase ankle braces to help prevent these injuries in the future? Certainly the best situation would be not to have any more ankle sprains. Unfortu nately, certain sports and activites place patients a higher risk for these inj Properly designed footwear fora glen sports advsable. Because of the side- to-side movements in racquetball, a higher ankle shoe could be helpul in sprain [prevention Ane braces ae aso availabe, and many ae self adjustabe fora Dbetor fit In adition, proper preparation for exercise, ike stvetching, could help lower the isk of injuries. Key: NKA, no known allergies; NSAID, nonsteroidal antinlammatory drug; PCP, primary care provider; RICE, est, ce, ‘compression, elevation. Patient Counseling for Musculoskeletal Injuries and Disorders Printed materials reinforce verbal information, Many such pam- phlets oF single-page handouts are available fom national pro- fessional societies (eg, wwwarthrits.org), including those chat (Consultation withthe patient should include explanation of the expected benefit of any recommended medication, the appeo~ priate dose and drug administration schedule, potential adverse reactions, potential drug-drug or druge-disease interactions, and sel monitoring techniques for asessing response to therapy. The consequences of nonadherence should be emphasized. ‘educate on various chronic pain syndromes such as osteoarthri- tis. These materials offer advice on exercise, diet, and sleep habits, and the advantages as well as disadvantages of pharma cologic therapy. Generally chese materials can be obtained for, free or for a nominal delivery fee. Health care providers may. ‘wish to design their own supplementary materials,‘Musculoskeletal Injuries and Disorders. CHAPTER 7 m1 Patients taking NSAIDs should be warned about possible drug-drug interactions, including antihypertensive medica tions, warfarin, aspirin, and phenytoin, and drug-disease inte actions such at heare failure and renal insufficiency. Patients should be cautioned not to take more than the recommended, nonprescription dose or to exceed the recommended duration ‘of treatment, Duplication of acetaminophen and NSAIDs is probably more common than recognized, because patients ‘often do not realize that nonprescription products contain the same of similar drugs found in their prescription drug. Fail- ure to recognize this duplication can significantly increase the risk of serious adverse events and patients should be wamed of the risk. In acute pain management, early administration ‘of nonprescription analgesics should be employed to prevent PATIENT E Musculoskel ‘The objectives of sele-treatment are to (1) reduce the severity and duration of pain, (2) estore function of the affected area, (3) pre- vent reinjury and disability, and (4) prevent acute pain from ‘becoming chronic persistent pain. Certain nondrug measures and ‘nonprescription counteriritants can relieve the symptoms of pain ‘rom a sudden and recent muscle, tendon, or ligament injury: an ‘overuse injury (tendonitis, Bursts, or repetitive stress injury); low ‘back pain; or arthritis. For mast patients, careful following prod- uct instructions and the self-care measures listed here wal help ‘ensure optimal therapeutic outcomes. Nondrug Measures ' For pain related to muscle or joint injures, begin treatment with RICE therapy (see Table 7-3). 1 For periodic mace cramps, setch and massage the affected ‘area immediately; then rest or reduce activity of the muscle to ‘low ito loosen 1 For persistent cramps, apply heat to the affected area in the form of a warm wet compress, 3 heating pad, ora hot water bottle ' For osteoartrtis, ty a combination of nondrug measures, including applying heat or cold to the affected area, support= ing the area with splints, and doing range-of maton and ‘svength-maintenance exercises. Preventive Measures = To prevent muscle or joint strains and sprains, do warm-up and stretching exercises before playing sports or exercising, ‘and wrap injured muscle or joint with protective bandage oF tape. 1 To prevent repetitive svain, exercise the muscles that are vwlnerable to the injury, and use ergonomic controls to adjust posture, stresses, motions, and other damaging phys- ical factors 1 To prevent tendonitis and cramps, warm up and stretch mus- es before physical activity, drink suficientflids, and do not ‘exercise tothe point of exhaustion, To help prevent noctumal leg ezamps, raise the foot ofthe bed. If you have Achiles ten- dons, ry wearing beter fing shoes wth hel ifs to reduce. the symptoms. 1 To prevent or reduce the occurrence of low back pai, do exer- Gees to strengthen the muscles ofthe lower backand abdomen, ‘and use assistive devices (.., cane or walker if needed. 1 To prevent or reduce the occurence of osteoarthritis, avoid 3 sedentary lifestyle, keep the joints active, lose weight i over- ‘weight, and use asistive devices if needed. escalating pain, with downward tapering of the analgesic doses as pain severity allows, generally Ito 2 days after the precip- stating event Patients should be instructed to notify their primary care provider whenever the pain changes in character or severity, oF if new acute pain develops, Other sudden uncharacteristic pains may be harbingers of new eisue damage, Patents should be advised 0 ‘oben their prescriptions fiom as few prescribers as possible and to get their prescriptions drugs, nonprescription drugs, and complementary remedies at the same phatmacy to minimize the potential for drug interactions The box Patient Education for Musculoskeletal Injuries and Disorder ists specific information to provide patients about topical analgesics and preventive and nondrug measures. Nonprescription Medications ® Formild-to-moderate muscle pain, take 3 nonprescription fnalgesic for no longer than 7 days ee Chapter 5 for alisting of nonprescrition analgesics) and/or a topical courterinitant(2e Table 7-4 for recommended dosages of counterritants. ' Do not use counteiitans if your sknis abraded, sunburned, Cor othenvise damaged. = When using counteriritants, wash your hands after application and before touching your eyes and mucous membranes, oF before handling contact lenses. * Gently ub 3 thin layer of countercitant product into affected ‘muscles orjints until you cannot see the product. Thick apph Cation ofthe praduct does not make the product work better. 1 Do not put atight bandage or dressing over an area treated with 2 counteriritant. Do not use warming devices with counteritants "= Donot treat a child 2 years of age or younger with counterin- tants unless a primary eae provider supervises the use 1 Ifyou have arthritis, onsut your dector before attempting to ‘west your pain with counteritants or with topical or internal analgesics. ™ Ifyouhave asthma, and symptoms of wheezing and shortness cof breath worsen vile you are using @ mentholated formula- tion, stop using it 1 Do not use ary product containing salicylates (including aspirin, ‘methyl salicylate, and wrolamine salicylate if you are receiving anticoagulation therapy (especialy wart) ® Ifa counterritant causes excessive redness and blistering or hives and vomiting, top using it a Die eretence nisen, voi, cle and other brsval proms wl using» prodt conan cm Plex sek mca carota Baiivspen ee reser rae an 2 ees or yo tought veament orhas wrened, const primary cre prover Aiesrmescesperssater mre han dys ofearent rif the pain is constant and felt in any postion, consult a primary care provider.112 SECTION 11 _ Pain and Fever Disorders Evaluation of Patient Outcomes for Musculoskeletal Injuries and Disorders The primary indicator of treatment effectiveness isthe patient's perception of pain relief. Ia patient reports the pain i ill pres- tent of has worsened afer 7 days of using nonprescription anal- esis, the health care provider should refer the patient for farther evaluation. In many instances, the lack ofa return visi indicates a suecessfil treatment regimen, Patients with minor sprains oF strains will not require a second visit asthe tissues heal and they return to normal function. Ifthe health care provider has a good relationship with the patient, he or she may call the patient ina few days to determine whether the complaint has resolved. However, a patient who does return with signs of continued swelling, pain, or inflammation should be referred for medical evaluation. The continued pain may indicate an ‘ongoing process that could lead co long-term disability or decreased mobility, Key Points for Musculoskeletal Injuries and Disorders > Self-treatment of patients presenting with pain secondary to an injury or a disorder of the musculoskeletal system should be limited to those with mild-to-moderate pain who have no exclusions for sel- treatment such as a visibly deformed joint or systemic symptoms (Figure 7-2). > Selfereatment of acute musculoskeletal injuries should include nondrug therapy, such as res, ice, compression, and elevation (RICE), Heat cherapy may also provide ben- efit after swelling abates > Patients self-¢reating the chronic pain of osteoarthritis should be advised to employ nondrug therapy such as weight loss, exercise and stretching, and use of asistive devices (ies, cane), > Clinicians should advise patients on the proper selection of 4 product for their musculoskeletal injury or disorder, tak- ing into account the patients preferences > Systemic analgesics are valid first-line treatments for the iajority of musculoskeletal injuries and disorders. Acet= aminophen is preferred in noninflammatory diseases, ‘whereas NSAIDs are preferred if inflammation is present. Side effects and drug interactions should be considered before therapy is chosen (sce Chapter 5). > Topical counterirritants are useful for treatment of acute ‘musculoskeletal injuries and asan adjunct in the treatment of | chronie musculoskeletal disorders, They are to be used only topically and on skin that is intact. Patients should be advised ‘not to use heating devices with topical counterirritants oF t0 ‘cover the counteriritant with a tight bandage. > Complementary therapy with glucosamine may provide ‘benefit in patients with mild-to-moderate osteoatthits of| the knee. > Health care providers should monitor the outcome of self treatments and advise patients who self-treat their acute musculoskeletal injury to seek medical attention if their symptoms do not improve after 7 days > Health care providers ean assist patients through direct support and education by counseling in a nonjudgmental way and providing other resources to help manage their pa REFERENCES 1. Locier JB, Melack R. Pain: an overview [review]. Las. 19,53: a7, 2. Meme , Simons DG, Resell]. Mule Pin Undetanding is Nat, Dispos and Trent Baeore: Lippitt Walia & Walkin: 2001: 122. 3. Hicher Reach Group, Analgesic the rene sarc for ree: Dag “Top. December 13, 20 4. Stewart WE, Rice JA. 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