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03/04/2021
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Pain ManagementIn Best Practice
dr. Hardhi Pranata, Sp.S, MARS
PDHMI (Perkumpulan Disiplin Herbal Medik Indonesia)
- 21 Maret 2021 -
PAIN
unpleasant sensory & emotional
Psychological & certain autonomic (involuntary) responses
behavioural reactions provoked by tissue damage.
A COMPLEX CONSTELLATON:
International Association for the Study of Pain (IASP)
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Pain & Covid-19
•Chronic pain management during the coronavirus disease 2019 (COVID-19) pandemic is a challenging process, especially with growing evidence that COVID-19 infection is associated with headache, myalgia, referred pain, and widespread hyperalgesia
Tallawy et al., 2020
• Biochemical Theories pain-producing, pain- mediating and pain chemoreceptors are located in the brain Endogenous opiates – inhibits pain by blocking substance P. in Periacquedactal gray area
• Chemical pain mediators and inhibitors:Bradykinin, Histamine, prostaglandin
Theory of Pain:
BIOCHEMICAL THEORY
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•Glutamate - Central•Substance P - Central•Brandykinin - Peripheral•Prostaglandins – Peripheral•Aspartate
Pain Initiators
•Serotonin•Endorphins•Enkephalins
Pain Inhibitors
NEUROTRANSMITTERS
•Dynorphin•GABA•Glycine
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PAIN CLASSIFICATION
1. Acute
2. Chronic :
a) Non malignant
b) Malignant
Types of Pain
Nociceptive
Somatic Visceral
Neuropathic
Peripheral Central
Mixed
TYPES OF PAIN
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Modulation
Mediators of Nociceptive Pain
• Nociceptors are specifically designed receptors to detect stimuli that may cause
harm to the body, which may be mechanical, chemical or thermal in nature.
• Aᵟ fibres mediate sharp localised pain
• C fibres mediate dull and burning pain
3. Mixed Pain2. Neuropathic:1. Nociceptive:
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Nociceptive pain may be somatic or visceral in origin.
-Visceral pain: Originates in nociceptors located in the
hollow organs and smooth muscles; it is often referred. E.g.
Dysmenorrhea, gastritis, appendicitis or acute pancreatitis
-Somatic pain: Originates from musculoskeletal,
joint or cutaneous nociceptors and is often well
localized. E.g. Gout, osteoarthritis, skin incision
and trauma-induced pain.
3. Mixed Pain2. Neuropathic:1. Nociceptive:
▪ Caused by pressure on &/or destruction of
peripheral, autonomic or central nervous system
structures.
▪ May arise from a lesion or trauma, infection,
compression or tumour invasion.
▪ Described as burning, shooting, tingling.
▪ Does not respond well to standard analgesics.
3. Mixed Pain2. Neuropathic:1. Nociceptive:
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Peripheral Neuropathic Pain:Central Neuropathic Pain:
3. Mixed Pain2. Neuropathic:1. Nociceptive:
• Central post stroke pain
• Neuropathic associated with spinal cord injury
• Traumatic brachial plexus injury• Diabetes Mellitus• Carpel tunnel syndrome• Post herpetic neuralgia
Recognizing Neuropathic Pain
Be alert for common verbal descriptors of neuropathic pain:
Burning Tingling Shooting Electric shock-like Numbness
3. Mixed Pain2. Neuropathic:1. Nociceptive:
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INSTRUMENTS FOR ASSESSING
PAIN PERCEPTION• VISUAL ANALOGUE SCALES(VAS)
Goals of Pain Management
Therapy
1) Decreased pain
2) Decreased healthcare utilization
o Decreased “shopping” for care
o Decreased emergency room visits
3) Improved functional status
o Increased ability to perform activities of daily living
o Return to employment
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Pregabalin
GENERAL APPROACH TO PAIN THERAPY
Management
• Non-Pharamcological treatment
• Pharmacological treatment:
• Analgesics
• Adjuvants
• Others
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PAIN THERAPY
Non-pharmacological
Intervention
Pharmacological
Intervention
• Superficial Heat• Exercise• Cryotherapy• Acupuncture• Acupressure• etc
• Non opioid• Weak opioid• Strong opioid
PHARMACOLOGICAL INTERVENTION
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WHO 3-step Analgesic ladderPharmacological
Intervention
Analgesic ladder in action:
◼ Step 1: non-opioid analgesics (Paracetamol
and Aspirins, NSAIDS)
◼ Step 2: mild opioid is added (not
substituted) to step 1
◼ Step 3: Opioid for moderate to severe pain
is used and titrated to effect
Pharmacological Intervention
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• Used in full doses for the most part.
• All have a ceiling effect to their analgesia (a maximum dose
past which no further analgesia can be expected).
• COX-2 inhibitors may be associated with fewer side-
effects
a) Analgesics (Non-opioids)
Pharmacological Intervention
• Use cytoprotection with NSAIDs only in
patients who have symptoms suggestive of
GI distress or who are at high risk of ulcer
formation.
• For cytoprotection use sulcrafate or
misoprostol.
Pharmacological Intervention
a) Analgesics (Non-opioids)
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b) Analgesics (Weak Opioids)
• Codeine & codeine combination products
USEFUL
• Morphine , hydromorphone, fentanyl,
oxycodone , methadone.
c) Analgesics (Strong Opioids)
USEFUL
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Adjuvant analgesics (coanalgesics)
▪ Are medications that when added to primary
analgesics, further improve pain control.
▪ may themselves also be primary analgesics (e.g.
tricyclic antidepressant medications for postherpetic
neuralgia).
▪ They can be added into the pain management plan at
any step in the WHO ladder.
▪ Cyclic Antidepressants:
o Amitriptyline
▪ Anticonvulsants:
o Carbamazepine - Valproic acid - Gabapentin - Pregabalin
▪ Local Anesthetics:
o Lidocaine
Adjuvants for Neuropathic Pain
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Other modalities
▪ Nerve blocks, epidural blocks and ablative
neurosurgical procedures may be effective in pain
management.
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OMAI
OHT Terstandar kandungannyaUji pra-klinik keamanan & khasiatnya
eg:HerbapainBodrex HerbalKiranti pegel linuRheumakurNeo Rheumacyl Herbal PainNeosendiDismeno
Obat Bahan Alam Indonesia
FitofarmakaUji praklinik & uji klinik
eg:• Inlacin (Kayu Manis) untuk diabetes mellitus• Redacid untuk gastritis• Stimuno (meniran) untuk meningkatkan
imunitas• Disolf untuk stroke
Herbal Anti-Nyeri/ Inflamasi
Cengkeh (Syzygium aromaticum)
Kandungan utama: Eugenol. Kaempferol, Quercetin
Uji PraKlinik: Dapat mengurangi radang pada tikus dengan caramenghambat induksi InterLeukin-8 (IL8) pada makrofag
Indikasi: Nyeri pada gigi, dan sebagai topikal
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Herbal Anti-Nyeri/ Inflamasi
Jahe (Zingiber officinale)
Kandungan utama: Cineol, Gingerol, Zingiber
Uji Laboratoris: Mengahambat sintesa prostaglandin dan leukotriene
Indikasi: AntiNyeri, Anti-radang sendi
Herbal Anti-Nyeri/ Inflamasi
Cabe (Capsicum annum L.)
Kandungan utama: Capcaisin, Zea Xanthine, Lutein
Uji PraKlinik: Capcaisin menyebabkan rasa nyeri terbakar pada daerah kulit melalui mekanisme pelepasan neuro-peptide (substansi P) sehingga menghilangkan nyeri nociceptive & neuropatik
Indikasi: Topikal menghilangkan nyeri pada otot
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Herbal Anti-Nyeri/ Inflamasi
Serai (Cymbopogon citratus)
Kandungan utama: Cytronelal, Geraniol
Uji PraKlinik: Ekstrak rebusan serai menginhibisi nyeri
Indikasi: Sebagai Minuman untuk mengurangi nyeri
Herbal Anti-Nyeri/ Inflamasi
Temulawak (Curcuma xanthorrhiza)
Kandungan utama: Curcumin, Xanthorizol, Turmeron
Uji Klinik: (Nyoman Kertia, 1997) 22 pasien OA lutut
Diberikan 15mg curcuminoid + 200mg atsiri temulawak
- 2x sehari ---- selama 14 hari
Indikasi: AntiNyeri, Anti-radang sendi
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Herbal Anti-Nyeri/ Inflamasi
Kunyit (Curcuma longa)
Kandungan utama: Curcumoid, Turmeron, Zingiberon
Uji PraKlinik: Menghambat fase lipo-oksigenase dan siklo-oksigenase sehingga sintesa prostaglandin-2 menurun
Indikasi: Anti-Nyeri, Anti-Radang sendi
Herbal Anti-Nyeri/ Inflamasi
Mahkota Dewa (Phaleria macrocarpa)
Kandungan utama: Alkaloid, Flavonoid, Lignan, Saponin
Cara Kerja: Menghambat fase lipo-oksigenase dan siklo-oksigenase sehingga sintesa prostaglandin-2 menurun
Indikasi: Nyeri kepala, nyeri otot
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Penggunaan DLBS1442 DALAM MenGURANGI Nyeri
Mekanisme Kerja DLBS1422
• Kandungan flavonoid, fenol, terpenoid, terbukti dapat mengurangiinflamasi dengan cara menekan pelepasan prostaglandin oleh jalurpenghambatan COX-2
• Selain itu, aktivitas antioksidan dari Mahkota Dewa juga berperandalam penghambatan nitric oxide (NO) yang berperan dalam prosesinflamasi
Hendra et al. Antioxidant, Anti-inflammatory and Cytotoxicity of Phaleria macrocarpa (Boerl.) Scheff Fruit. BMC Complementary and Alternative Medicine 2011:11;1-10.
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Uji Praklinik Serbuk Ekstrak Kering Tumbuhan DLBS1442 (mahkota dewa)
sebagai Antinyeri
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Soemardji AA, Safitri D, Rahmawati SF. Preclinical study of DLBS1442 as analgesic (Siegmund method). Institut Teknologi Bandung, Bandung 2016. Data on file.
Tujuan penelitian
untuk menguji aktivitas DLBS1422 dalam meredakan nyeri
Dosis penggunaan
200 mg atau 0.2 gram untuk orang dewasa (70 kg) setara dengan dosis 0,026 g/kgBB mencit
Obat pembanding
Natrium diklofenak dan Ibuprofen (dosis obat pembanding yang digunakan setara dengan dosis pemakaian pada manusia dewasa 70 kgBB)
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Soemardji AA, Safitri D, Rahmawati SF. Preclinical study of DLBS1442 as analgesic (Siegmund method). Institut Teknologi Bandung, Bandung 2016. Data on file.
Metode Penelitian
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Profil jumlah geliatan mencit setiap 10 menit selama waktupengamatan
Kesimpulan:Dari hasil analisis statistik, kelompok yang diberikan dosis rendah (0,026 g/kgBB) dandosis tengah (0,052g/kgBB) memiliki geliatan/writhing response (respons rasa sakit)yang lebih rendah secara bermakna dibandingkan dengan kelompok kontrol
Soemardji AA, Safitri D, Rahmawati SF. Preclinical study of DLBS1442 as analgesic (Siegmund method). Institut Teknologi Bandung, Bandung 2016. Data on file.
Symptomatic treatment of premenstrual syndrome and/or primary dysmenorrhea with DLBS1442, a bioactive extract of Phaleria macrocarpa
Tjandrawinata RR, et al. Symptomatic treatment of premenstrual syndrome and/or primary dysmenorrhea with DLBS1442, a bioactive extract of Phaleriamacrocarpa. International Journal of General Medicine 2011:4 465– 476
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Pain in the stomach Breast Pain Back Pain
Headache
Dari penelitian ini didapatkan bahwaefektivitas dari DLBS1442 (Predimenol) dapat meringankan simptom nyeri yang disebabkan oleh PMS dimana secarakeseluruhan menunjukkan VAS score yang lebih rendah setelah diberikan DLBS1442
Tjandrawinata RR, et al. Symptomatic treatment of premenstrual syndrome and/or primary dysmenorrhea with DLBS1442, a bioactive extract of Phaleria macrocarpa. International Journal of General Medicine 2011:4 465– 476
DLBS1442
• Memiliki efek anti-inflamasi dengan cara menekan COX2-mRNA
• Sehingga terjadi penurunan Prostaglandin-E2 (PGE2)
• Buah mahkota dewa juga menghambat xanthine oksidase dan lipo-
oksigenase
• DLBS1442 berfungsi sebagai moderate anti-inflamasi
Hasil formulasi dari ekstraksi teknologi tinggi dari buah mahkotadewa (Phalia marcocarpa) pada uji laboratorium
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RAMUAN IMUNOMODULATOR
Komposisi:
- Sambiloto, Meniran, Akar Manis, Jahe Emprit, Daun Jambu Mede
Kandungan: Lakton, kolmegin, andographolid
Khasiat: Anti nyeri, Anti radang, Anti virus, Anti bakteri
SAMBILOTO (Andrographis paniculata)
Kandungan: Phylantin, Mirantin
Khasiat: Anti virus, Anti bakteri
MENIRAN (Phyllanthus urinaria)
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Kandungan: Gingerol, Shogaol, Zingiberol
Khasiat: Anti kembung, Anti mual, Anti radang, Anti bakteri
JAHE EMPRIT (Zingiber officinale var. amarumdengan)
Khasiat: Mengurangi sesak napas,
mengurangi dahak, anti virus, anti nyeri
DAUN JAMBU MEDE (Anacardium occidentale)
RAMUAN IMUNOMODULATOR
Kandungan: Flavonoid, Glycyrrhizin, Licorice
Khasiat: Melancarkan pernapasan, mengurangi batuk, anti nyeri lambung, anti bakteri
RAMUAN IMUNOMODULATOR
AKAR MANIS (Glycyrrhiza glabra)