SEKILAS

PENATALAKSA
NAAN NYERI
Dr. AWALUDDIN NOOR, Sp.S

Prima Resort Kuningan

9 April 2010
Definisi Nyeri (Pain) dari
IASP (International Association for the Study of Pain)

Pain (Nyeri) adalah suatu Nyeri adalah

pengalaman sensorik dan pengalaman sensorik
emosional yang berkaitan yang berkaitan
dengan kerusakan dengan aktivasi
jaringan atau diduga ada nociceptor dan
kerusakan jaringan lintasan nyeri
Nyeri adalah suatu
pengalaman
emosional
Kerusakan jaringan
tidak mesti ada
 JENIS NYERI

Neuropathic Pain Inflammatory Pain

Mixed Pain
Pain initiated or caused by a Pain with Pain caused by injury to
primary lesion or dysfunction neuropathic and body tissues
in the nervous system nociceptive (musculoskeletal,
(either peripheral or components
cutaneous or visceral)2
central nervous system)1

Examples Examples
Peripheral Examples
Post herpetic neuralgia Pain due to inflammation
Trigeminal neuralgia Low back pain with
radiculopathy
Limb pain after a fracture
Diabetic peripheral neuropathy Joint pain in osteoarthritis
Postsurgical neuropathy Cervical
radiculopathy
Postoperative visceral pain
Posttraumatic neuropathy
Central Cancer pain
Common descriptors2
Posts troke pain Carpal tunnel
syndrome
Aching
Common descriptors2 Sharp
Burning Throbbing
Tingling
Hypersensitivity to touch or cold

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
 Neuropathic Pain is
Different from
Muscle/skeletal
Neuropathic Pain
Pain
Muscle/skeletal Pain

Chronic pain (months/years) Acute pain (hours or days)

Caused by injury or disease to nerves Caused by injury or inflammation that

affects both the muscles and joints

Mild to excruciating pain that can last Moderate to severe pain that
indefinitely disappears when the injury heals

Causes extreme sensitivity to touch Causes sore, achy muscles

simply wearing light clothing is
painful

Sufferers can become depressed or Sufferers can become anxious and

socially withdrawn because they see distressed but optimistic about relief
no relief in sight and may experience from pain
sleep problems
Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97;
Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L.
Cecil Textbook of Medicine. 21st ed; 2000
Symptoms of Neuropathic Pain
Characterized Differently
Neuropathic Pain Muscle/Skeletal Pain

Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997; Galer BS et
al. Diabetes Res Clin Pract. 2000;47:123-128
Neurophatic
pain

Nociceptive/
imflammatory/
musculoskletal
pain
 Thick, myelinated, fast
conducting neurons
Mediate the feeling of initial
fast, sharp, highly localized
pain.
Very thin, unmyelinated, slow-
conducting
Mediate slow, dull, more
diffuse, often burning pain.

Rabaan
Tekanan
Nerve Fibers
Class Velocity Function
A- Fast Motor
A- Fast Touch,
pressure
A- Intermediate Muscle tone

A- Intermediate Pain,
temperature
B Small Motor
C Small Pain
 Targets of Pain Therapies
Pharmacotherapy
Non-opioid analgesics
Opioid analgesics
Nerve Blocks
Adjuvant analgesics (neuropathic,
tramadol musculoskeletal)

Acetaminofen Electrical Stimulation

Transcutaneous electrical nerve
stimulation (TENS)
Percutaneous electrical nerve
stimulation (PENS)

Alternative methods
Acupuncture
(NSAID) Physical Therapy
Chiropractics
Gottschalketal.,2001 Surgery
 ABC Tx. Nyeri
Anamnesa nyeri secara sistematik dan
teratur
Berpikiran positif (percaya) terhadap
keluhan pasien atau keluarga
Carilah metode kontrol nyeri yang nyaman
untuk pasien dan keluarga
Dilakukan intervensi yang tepat waktunya,
logis dan terkoordinasi
Edukasi pasien dan keluarga untuk
mengatasi nyeri sekuat mungkin
Analgesics
Non-opioid analgesics (non-opioids):
paracetamol, acetylsalicylic acid, metamizole* and
nonsteroidal anti-inflammatory drugs (NSAIDs).

Opioid analgesics (opioids):

weak opioids (codeine, dihydrocodeine,
tramadol) and strong opioids (i.e., morphine).
Papaver somniferum

Co-analgesics: a diverse group of drugs, with primary

indications for conditions other than pain, with analgesic
properties relevant to some conditions. Commonly used
adjuvant analgesics include antiepileptic drugs (AEDs), tricyclic
antidepressants (TCAs) and local anaesthetics (LAs).
Diagnosis Drug Treatment
Acute and chronic pain NSAIDS , Opioids (al tramadol),
Paracetamol

Myofascial pain Analgesics , tricyclics,

dysfunction centrally-acting muscle
relaxants, glucocorticoids

Neuropathic pain, Carbamazepine, phenytoin,

neuralgias baclofen, tricyclics,
gabapentin, others?
Acetaminophen
May inhibit COX selectively in central nervous
system
Only weak inhibitor of peripheral COX (peroxide
effects?)
Inhibits effects of substance P in CNS?
Inhibits effects of glutamate in CNS?
 Paracetamol

1. Paracetamol is an effective analgesic for acute pain

(Level I*).
2. Paracetamol is an effective adjunct to opioids (Level I).
3. NSAIDs given in addition to paracetamol improve
analgesia (Level I).
4. IV paracetamol is an effective analgesic after surgery
(Level II), is as effective as ketorolac (Level II) and
equivalent to morphine after dental surgery with better
tolerance (Level II).
 Mekanisme Kerja Tramadol
Dua mekanisme kerja yang saling melengkapi:

1. Kerja di opioid: 2. Kerja di monoaminergic:

- Agonis reseptor Menghambat re-uptake
- Metabolit aktif serotonin/noradrenalin
(O-desmethyl-
tramadol/M1)
Mekanisme Kerja Tramadol

Tramadol
Menuju Otak Descending pathway

Neuron dari saluran spinothalamic

Serotonin/Noradrenalin
-Receptor
2-Receptor
Tramadol
Transmiter nyeri

Spinal neuron Rangsang Nyeri

Enkephalin
 PAIN PHARMACOTHERAPHY

Choose drugs based on:

mechanism of pain
safety and pharmacology of aging
match pain severity with drug potency
use combined drug and non-drug strategies

Use adequate dose; appropriate route

Anticipate, prevent and manage side effects

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

Fixed combinations are appropriate for on-demand treatment

typically used in acute pain conditions and situations of non-stable
pain or intermittent pain in chronic conditions.

A fixed analgesic combination simplifies drug delivery without the

need for complicated dose-escalating regimens and, therefore,
improves compliance.

Free drug combinations

Free drug combinations are particularly appropriate for the

management of stable chronic pain syndromes.

The main advantage of free drug combinations is that they allow the
dose regimen to be tailored to individual requirements. On the other
hand, this may be time-consuming because it involves a gradual and
dose-escalating strategy.
 Kombinasi NSAID
Kombinasi 2 NSAID: Kombinasi NSAID
Tidak dianjurkan dengan Pelindung
Efek samping meningkat Lambung:
Tidak menambah efikasi
Ditujukan untuk sedikit
Kombinasi NSAID dan mengatasi masalah efek
Analgetik (paracetamol) samping terhadap
lambung.
Masih dapat Dapat diberikan bersama
dipertanggungjawabkan
golongan PPI,
Misoprostol
 ZALDIAR
(37,5 MG TRAMADOL PLUS 325 MG PARASETAMOL)

PHAROS INDONESIA
 Komposisi :
37.5 mg Tramadol plus 325 mg Taracetamol
Indikasi :
Mengurangi nyeri sedang sampai berat
Sediaan :
Tablet salut film

Kemasan :
Box isi 10 tablet
Harga 1 box : Rp 65.000
Harga 1 tablet Rp 6.500
 INDIKASI ZALDIAR
Nyeri sedang sampai berat seperti :

Nyeri Pasca Operasi

Trauma karena
kecelakaan
Low-back pain
Nyeri Osteoarthritis

Tambahan pengobatan
pada OA/RA yang telah
Rehabilitasi pasca diberi NSAID/COX-2
Bedah minor
cedera olahraga
Dosis Untuk Dewasa (>12
Tahun)
Dosis ZALDIAR fleksibel tergantung dari
intensitas nyeri.
Untuk nyeri yang berat dosis awal bisa
2 tablet kemudian diberikan setiap 6 jam
Rata-rata dosis per hari 3-4 tablet
Maksimal 8 tablet per hari
(Sama dengan 300 mg tramadol/2600 mg parasetamol)
ZALDIAR: Onset cepat durasi
lama
4
Pain relief probabilities

Tramadol/paracetamol
2

Paracetamol
1

Tramadol
0
0 2 4 6 8 10

Waktu (jam)

Kerja analgesik yang saling melengkapi:

Onset cepat dari parasetamol dikombinasi dengan durasi lama dari
tramadol
Perhatian pada kelompok
pasien berikut :
ZALDIAR jangan diberikan pada:
Anak-anak <12 tahun
Selama hamil
Selama menyusui
Kategori ZALDIAR C
Kontraindikasi
Hipersensitif terhadap tramadol dan parasetamol
Acute intoxication alkohol, hypnotic, analgesik
sentral, opioids atau obat psychotropic
Pemberian bersamaan dengan MAO inhibitor or
within two weeks of withdrawal
Gangguan fungsi hati berat
Epilepsi yang tidak sedang dalam pengobatan
Peringatan
Dosis maksimal 8 tablet per hari
No concurrent use of any other products containing
paracetamol or tramadol
Tidak direkomendasikan pada pasien dengan
gangguan ginjal (creatinin clearance <10ml/mm)
Jangan diberikan pada pasien dengan gangguan
hati berat
Tidak direkomendasikan pada pasien dengan
gangguan pernafasan berat
Interaksi
Kontra indikasi / tidak direkomendasikan
digunakan bersamaan dengan:
MAO inhibitors, Alcohol,
Carbamazepine, Opioid agonists-
antagonists
STUDI KLINIS
Nyeri setelah bedah mulut
(gigi)
Medve RA et al. Anesthesi Prog, 2001

Tujuan:
Membandingkan efikasi dan keamanan dari
tramadol/parasetamol (ZALDIAR) dengan tramadol atau
parasetamol monoterapi
Dosis:
Tramadol 75 mg/parasetamol 650 mg
75 mg tramadol
650 mg parasetamol
400 mg ibuprofen
Plasebo
Desain penelitian:
1200 pasien dengan nyeri sedang sampai berat
setelah bedah (cabut) gigi geraham paling belakang
(geraham bungsu) yang di random menjadi 3, double
blind, paralel group, studi dosis tunggal yang
diobservasi selama 8 jam.
Tiga pusat penelitian terdiri dari 400 pasien; yang
terdistribusi merata dalam pengobatan

Medve RA et al. Anesth Prog, 2001

 Hasil penelitian: efikasi

*P .0001 vs Tramadol/paracetamol; P = .0004 vs Tramadol/paracetamol;

P .0001 vs all active treatments

TOTPAR 8 = Total pengurangan nyeri dalam 8 jam

SPID = Jumlah perbedaan intensitas nyeri dalam 8 jam
Kesimpulan penelitian
ZALDIAR pada pasien bedah
gigi
Pengurangan / penurunan intensitas nyeri dengan
ZALDIAR lebih superior dibanding tramadol atau
parasetamol sendiri atau plasebo
Mula kerja ZALDIAR lebih cepat dan durasi kerja lebih
lama dibanding tramadol atau parasetamol sendiri.
Masing-masing komponen dari ZALDIAR berkontribusi
terhadap efikasi analgesik
ZALDIAR adalah analgesik kuat dengan
onset cepat, durasi panjang yang efektif
dalam pengobatan nyeri akut
Efek samping setelah
pemberian ZALDIAR ( 5%)
Tramadol/ Tramadol Paracetamol Ibuprofen Placebo
paracetamol (n=238) (n=240) (n=240) (n=239)
(n=240)

Nausea 56 (23%) 56 (24%) 22 (9%) 23 (10%) 38 (16%)

(mual)
Vomiting 51 (21%) 49 (21%) 17 (7%) 16 (7%) 23 (10%)
(muntah)
Dizzines 11 (5%) 12 (5%) 10 (4%) 7 (3%) 9 (4%)
(pusing)
Hasil penelitian: onset (mula kerja)
Hasil penelitian: durasi kerja
 Pain: A conceptual approach to treatment (Biopsycosocial
approach)

Anti-depressants /
Cognitive therapies psychotropics
Functional restoration Pain Behaviors Relaxation
Spiritual
Suffering

Pain
Opioid Perception
Adjuvants
NSAIDs?
Local block
Acetaminophene Nociception
NSAIDs (Movicox )
Neural augmentation Surgery
Ablative surgery Physical modalities

1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3.
Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.
HATUR NUHUN