[DGRh recommendations for the implementation of current security aspects in the NSAID treatment of musculoskeletal pain]

[The challenges of managing thoracic pain in cystic fibrosis (CF)]

BACKGROUND

Cystic fibrosis (CF) is a rare genetic multisystemic disorder with progressive abdominal and pulmonary involvement. Pain is still an underestimated symptom in CF patients.

METHODS

A comprehensive review of guidelines and scientific literature on the topic was performed and combined with findings from pain management in a young CF patient with progressive thoracic pain.

RESULTS

German CF guidelines do not cover diagnosis and management of pain in these patients. Studies from Europe and the United States report interactions between intensity of pain and mortality in CF, but do not include data on the efficacy of pain management. These data and clinical observations of a CF patient with episodes of intense thoracic pain are used to illustrate the specific challenges in pain relief.

CONCLUSION

Pain management in CF requires meticulous monitoring as well as an interdisciplinary approach and should be implemented in the German CF guidelines. The authors also want to suggest recommendations for the treatment of thoracic pain in CF. The range and severity of organ involvement complicates the use both of opioids and non-opioids. Especially opioid treatment carries the risk of hypoxia and opioid-induced constipation (OIC) and needs close medical supervision.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

BACKGROUND

Nonopioid analgesics are frequently used for perioperative analgesia; however, insufficient research is available on several practical issues. Often hospitals have no strategy for how to proceed, e.g., for informing patients or for the timing of perioperative administration of nonopioid analgesics.

METHODS

An expert panel representing the German national societies of pain, anaesthesiology and intensive care medicine and surgery developed recommendations for the perioperative use of nonopioid analgesics within a formal, structured consensus process.

RESULTS

The panel agreed that nonopioid analgesics shall be part of a multimodal analgesia concept and that patients have to be informed preoperatively about possible complications and alternative treatment options. Patients' history of pain and analgesic intake shall be evaluated. Patients at risk of severe postoperative pain and possible chronification of postsurgical pain shall be identified. Depending on the duration of surgery, nonopioid analgesics can already be administered preoperatively or intraoperatively so that plasma concentrations are sufficient after emergence from anesthesia. Nonopioid analgesics or combinations of analgesics shall be administered for a limited time only. An interdisciplinary written standard of care, comprising the nonopioid analgesic of choice, possible alternatives, adequate dosing and timing of administration as well as surgery-specific policies, have to be agreed upon by all departments involved. At discharge, the patient's physician shall be informed of analgesics given and those necessary after discharge. Patients shall be informed of possible side effects and symptoms and timely discontinuation of analgesic drugs.

CONCLUSION

The use of nonopioid analgesics as part of a perioperative multimodal concept should be approved and established as an interdisciplinary and interprofessional concept for the adequate treatment of postoperative pain.

[Perioperative analgesia with nonopioid analgesics : Joint interdisciplinary consensus-based recommendations of the German Pain Society, the German Society of Anaesthesiology and Intensive Care Medicine and the German Society of Surgery]

Hintergrund

Nichtopioidanalgetika werden bei vielen Patienten zur perioperativen Analgesie eingesetzt. Zu einigen praktischen Fragen beim Einsatz von Nichtopioidanalgetika liegen z. T. nur wenig Informationen aus Studien vor, und in Krankenhäusern existieren häufig keine Konzepte zum Vorgehen, z. B. zur Patientenaufklärung und zum Zeitpunkt der perioperativen Gabe.

Methodik

Eine Expertengruppe der beteiligten Fachgesellschaften hat konsensbasierte Empfehlungen zum perioperativen Einsatz von Nichtopioidanalgetika erarbeitet und in einem strukturierten formalen Konsensusprozess verabschiedet.

Ergebnisse

Die Arbeitsgruppe stimmt überein, dass Nichtopioidanalgetika Bestandteil eines perioperativen multimodalen Analgesiekonzepts sein sollen und Patienten präoperativ über Nutzen, Risiken und alternative Behandlungsmöglichkeiten aufgeklärt werden sollen. Die präoperative Patienteninformation und -edukation soll auch eine Schmerz- und Analgetikaanamnese umfassen und Patienten mit Risikofaktoren für starke Schmerzen und eine Schmerzchronifizierung sollen identifiziert werden. Unter Berücksichtigung von Kontraindikationen können Nichtopioidanalgetika abhängig von der Operationsdauer auch schon prä- oder intraoperativ gegeben werden, um nach Beendigung der Anästhesie ausreichende Plasmakonzentrationen zu erzielen. Nichtopioidanalgetika oder Kombinationen von (Nichtopioid‑)Analgetika sollen nur für einen begrenzten Zeitraum gegeben werden. Ein gemeinsam erarbeiteter abteilungsübergreifender Behandlungsstandard mit dem Nichtopioidanalgetikum erster Wahl, weiteren Therapieoptionen sowie adäquaten Dosierungen, ergänzt durch eingriffsspezifische Konzepte, soll schriftlich hinterlegt werden. Bei Entlassung aus dem Krankenhaus soll der nachbehandelnde Arzt zu perioperativ gegebenen und aktuell noch eingenommenen Analgetika schriftliche Informationen erhalten. Patienten sollen zu möglichen Nebenwirkungen der Analgetika und ihrer Symptome, die auch nach Krankenhausentlassung auftreten können, und die befristete Einnahmedauer informiert werden.

Schlussfolgerung

Die Anwendung von Nichtopioidanalgetika soll als Bestandteil eines perioperativen multimodalen Analgesiekonzepts mit klaren Vorgaben zu Indikationen, Kontraindikationen, Dosierungen und Behandlungsdauer in einem abteilungsübergreifenden Behandlungsstandard schriftlich hinterlegt werden.

Zusatzmaterial online

Die Offenlegung von Interessen ist in der Online-Version dieses Artikels (10.1007/s00104-021-01421-w) enthalten.

Risikostratifizierung in der Rheumatologie: Analgetika-Therapie

Auch im Biologika-Zeitalter ist Schmerz ein häufiges Symptom bei Patienten mit rheumatischen Erkrankungen. NSAR sind dabei unverändert meist Mittel der ersten Wahl. Insbesondere aufgrund ihres gastrointestinalen, kardiovaskulären und renalen Nebenwirkungspotenzials erfordert ihr Einsatz eine individuelle Risikostratifizierung beim Patienten in Abhänggigkeit von der zugrundeliegenden Erkrankung, den Komorbiditäten und der Komedikation.

Bei NSAR-Versagen oder -Unverträglichkeit stehen nur wenige Nichtopioid-Analgetika als Alternative zur Verfügung. Paracetamol ist häufig nicht ausreichend effektiv und bedarf eines hepatischen Monitorings. Beim Einsatz von Metamizol ist bei meist guter Wirksamkeit und allgemein guter Verträglichkeit über die sehr seltene Möglichkeit einer Agranulozytose und deren Symptome aufzuklären. Sofern auch hiermit keine zufriedenstellende Schmerzkontrolle möglich ist, können Opioide zum Einsatz kommen. Die Risikostratifizierung erfordert hier ein leitliniengerechtes Abwägen des zu erwartenden Nutzens in Abhängigkeit von der Grunderkrankung einerseits und den Risiken andererseits, wobei v. a. psychische Effekte einschl. Missbrauchs- und Abhängigkeitspotenzial, Übelkeit, Obstipation und erhöhtes Sturzrisiko im Fokus stehen.

Für die nahe Zukunft sind keine wesentlichen Neuentwicklungen bei den Analgetika zu erwarten, sodass die individuelle Risikostratifizierung für die derzeit verfügbaren Präparate langfristig entscheidend für eine optimale Therapie des einzelnen Patienten bleiben wird.

Prescription of analgesics in patients with rheumatic diseases in Germany : A claims data analysis

Objective

To investigate the prescription frequency of analgesics in persons diagnosed with rheumatoid arthritis (RA), axial spondylarthritis (axSpA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE) in 2019 using claims data.

Methods

Persons ≥ 18 years insured in 2019 with a diagnosis of RA (M05, M06), axSpA (M45), PsA (M07.0-3) or SLE (M32.1,8,9) were included. Analgesics were identified by the anatomic therapeutic classification (ATC) system. Reported is the percentage of individuals with ≥ 1 analgesics prescription for the respective rheumatic diagnosis in 2019 and for opioids age-standardized in each of the years 2005–2019. In addition, the proportion of long-term opioid use (prescriptions in ≥ 3 consecutive quarter years) in 2006 and 2019 is compared.

Results

Metamizole (29–33%) was the most commonly prescribed analgesic. Nonsteroidal anti-inflammatory drugs (NSAID)/coxibs were prescribed from 35% (SLE) to 50% (axSpA). Of the patients 11–13% were prescribed weak and 6–8% strong opioids. From 2005 to 2019, the proportion of persons with an opioid prescription remained stable, with similar or slightly decreasing proportions of weak opioids and more frequent prescriptions of strong opioids. The proportion of long-term opioid prescriptions increased from 2006 to 2019 from 8.9% to 11.0% (RA), from 6.9% to 9.1% (axSPA), from 7.8% to 9.5% (PsA), and from 7.5% to 8.8% (SLE), corresponding to a 17–24% increase.

Conclusion

The prescription of opioids for persons with inflammatory rheumatic diagnoses is not as high in Germany as in other countries; however, the proportion of long-term prescriptions has considerably increased. The frequent prescription of metamizole is conspicuous.

[Prescription of analgesics in patients with rheumatic diseases in Germany : A claims data analysis. German version]

OBJECTIVE

To investigate the prescription frequency of analgesics in persons diagnosed with rheumatoid arthritis (RA), axial spondylarthritis (axSpA), psoriatic arthritis (PsA) and systemic lupus erythematosus (SLE) in 2019 using claims data.

METHODS

Persons ≥ 18 years insured in 2019 with a diagnosis of RA (M05, M06), axSpA (M45), PsA (M07.0-3) or SLE (M32.1,8,9) were included. Analgesics were identified by the anatomic therapeutic classification (ATC) system. Reported is the percentage of individuals with ≥ 1 analgesics prescription for the respective rheumatic diagnosis in 2019 and for opioids age-standardized in each of the years 2005-2019. In addition, the proportion of long-term opioid use (prescriptions in ≥ 3 consecutive quarter years) in 2006 and 2019 is compared.

RESULTS

Metamizole (29-33%) was the most commonly prescribed analgesic. Nonsteroidal anti-inflammatory drugs (NSAID)/coxibs were prescribed from 35% (SLE) to 50% (axSpA). Of the patients 11-13% were prescribed weak and 6-8% strong opioids. From 2005 to 2019, the proportion of persons with an opioid prescription remained stable, with similar or slightly decreasing proportions of weak opioids and more frequent prescriptions of strong opioids. The proportion of long-term opioid prescriptions increased from 2006 to 2019 from 8.9% to 11.0% (RA), from 6.9% to 9.1% (axSPA), from 7.8% to 9.5% (PsA), and from 7.5% to 8.8% (SLE), corresponding to a 17-24% increase.

CONCLUSION

The prescription of opioids for persons with inflammatory rheumatic diagnoses is not as high in Germany as in other countries; however, the proportion of long-term prescriptions has considerably increased. The frequent prescription of metamizole is conspicuous.

Diclofenac in the treatment of pain in patients with rheumatic diseases

Diclofenac, a phenylacetic acid derivative, is a drug demonstrating high efficacy after oral administration in the treatment of pain and physical disability in rheumatic diseases. In view of the adverse effects associated with using diclofenac, it is necessary to consider all known drug safety information before the drug is selected for therapy and the dosage regimen is set for individual patients. Selecting an oral dosage form with specific properties determined by excipients is a method to improve the availability of the drug substance and, at the same time, minimize adverse drug reactions. An alternative to tablet or capsule dosage forms is diclofenac application to the skin. The proven efficacy of this method is further improved through the use of transdermal penetration enhancers and vehicle ingredients which provide dosage forms with specific physical properties.