Treatment of mild, moderate and severe pain in palliative patients

Joint pathologies require a comprehensive course of treatment using different methods - medication and physiotherapy, exercise therapy and special diets. All this allows you to relieve exacerbation and reduce the risk of relapse to the maximum. But sometimes joint pain is difficult or slow to relieve, and then intra-articular injections come to the rescue. Such procedures ensure the delivery of the drug directly to the inflammatory focus, resulting in rapid relief.

Injections for joints are prescribed for arthralgia - joint pain - of various origins and impaired mobility. They are used in the treatment of arthrosis and arthritis, gout, synovitis and bursitis. Thanks to the injection of drugs, damage to ligaments, tendons, knee menisci and cartilage is successfully treated.

Glucocorticosteroids (hormonal)

Hormones have a strong anti-inflammatory effect, due to which pain goes away and swelling subsides. Such drugs are prescribed in tablets and ointments, and are also injected intramuscularly. But intra-articular injections work much faster and better. An additional advantage of steroids is the low risk of systemic adverse reactions, since they enter the blood in a negligibly small volume. Painkilling injections for joint pain are given with medications such as:

• flosterone;
• diprospan;
• kenalog;
• hydrocortisone;
• celeston.

Hormones are administered either individually or in combination with vitamins and local anesthetics (Lidocaine).

Attention! Steroids are useless and even dangerous for septic – infectious – arthritis. It is treated with antibiotics, which are administered only after the joint has been washed.

Types of painkillers

Pain relief begins with the prescription of non-steroidal anti-inflammatory drugs (NSAIDs) in tablet form. These include Nurofen, Eferalgan, Nimesil, Diclofenac, etc. If they are ineffective, then at the second stage, combination drugs are prescribed to eliminate moderate pain. They include weak opiates and non-narcotic analgesics. Tramadol is most often prescribed from this group due to its effectiveness and ease of use. The third stage of pain therapy involves the prescription of narcotic analgesics, which help cope with even severe pain. These include buprenorphine, morphine, fentanyl, and omnopon.

Also, corticosteroids - preparations of adrenal hormones - are often used as analgesics. They have a powerful anti-inflammatory effect, especially important for pain caused by nerve compression, headaches caused by intracranial hypertension, and bone pain.

For each patient, medications are selected individually, so there is no universal scheme.

At any stage of pain therapy, analgesics must be taken regularly by the hour. The dose is adjusted taking into account the type and intensity of pain. If the drug becomes ineffective, it is advisable to replace it with an alternative drug of similar strength, but recommend it to the patient as more powerful.

Corticosteroids - preparations of adrenal hormones - are often used as analgesics. They have a powerful anti-inflammatory effect, especially important for pain caused by nerve compression, headaches caused by intracranial hypertension, and bone pain.

Anesthesiologist-resuscitator Vadim Sergeevich Soloviev about opioid analgesics:

Our doctors follow the principles of pain therapy proclaimed by WHO:

• “By mouth” (orally)
  means that all injectable forms of analgesics should be excluded and therapy should be carried out using non-invasive dosage forms (tablets, capsules, syrups, transdermal therapeutic systems, rectal forms of drugs, etc.).
• “On the clock”
  - analgesics should be prescribed regularly according to the schedule, in accordance with the duration of the drug’s effect, without waiting for the development of severe pain, excluding the possibility of “breakthroughs” of pain.
• “Ascending”
  - the selection of drugs for pain relief is carried out from non-opioid analgesics for mild pain, “mild” opioids for moderate pain and strong opioid analgesics for severe pain, as the pain intensity increases, in accordance with the “WHO pain management ladder”
• “Individual approach”
  - implies the need for an “individual” selection of an analgesic and is based on the selective selection of the most effective analgesic in the required dose with the least side effects for each individual patient, taking into account the characteristics of his physical condition.
• “With attention to detail”
  - involves taking into account the characteristics and details of each patient, of course, prescribing co-analgesics and adjuvant agents as the need arises, and monitoring patients.

Chondroprotectors

Such drugs are taken for degenerative-dystrophic diseases of the joints and spine to protect hyaline cartilage. The process of destruction of cartilage tissue during arthrosis and arthritis is progressive and irreversible. It can be slowed down with the help of chondroprotectors, which are especially effective when they “directly hit” the joint cavity. They improve local metabolism and nutrition of intra-articular tissues, and most importantly, stimulate the synthesis of their own collagen.

Collagen is the main component of cartilage, which performs a protective function. Thanks to the cartilage coating, the articular surfaces of the bones slide rather than rub, and movement does not cause pain. Most often, doctors prescribe Alflutop; the frequency and duration of the course is determined individually. The minimum number of injections is 5.

Injectable forms of NSAIDs - focus on the safety of therapy

However, the use of injectable forms of NSAIDs has its limitations, and one of the main problems here is the risk of developing local ADRs. Although serious complications with intramuscular injection of NSAIDs occur relatively rarely, the world literature contains numerous descriptions of health and life-threatening post-injection pathology. These include the formation of massive hematomas, damage to the sciatic nerve, subcutaneous and intramuscular abscesses (which R. Rotman-Pikielny et al. called “injectiositis”), sepsis, as well as Nikolaou syndrome, characterized by local embolization of the arteries with the development of acute tissue necrosis in the injection area [25–31]. R. Lardelli et al. (2020) [32] summarized the literature data on 62 episodes of Nicolau syndrome that occurred after IM injections of NSAIDs. The vast majority of cases were associated with the use of diclofenac (53 cases), another 2 cases each accounted for ketoprofen, ketorolac and phenylbutazone, and one each for etafenamate, ibuprofen and piroxicam.

NSAIDs with intramuscular administration, even when used for a short time, can cause a number of serious systemic class-specific (associated with blockade of COX-1 and COX-2) adverse events, primarily from the gastrointestinal tract, cardiovascular system (CVS) ) and kidneys.

In particular, the risk of developing gastrointestinal bleeding (GIB) when using NSAID injections (ketorolac) was studied in a large study by B. Strom et al. (1996) [33]. The authors assessed the incidence of this complication by comparing the results of 10,272 and 10,274 treatment courses of ketorolac and opioids used to control postoperative pain. It was shown that the use of ketorolac was associated with an increased risk of GIB by 30%. The odds ratio (OR) was 1.30 (95% CI 1.11–1.52). The risk of this serious adverse reaction was greatest in persons ≥75 years of age - OR 1.66 (95% CI 1.23-2.25) and when using ketorolac for more than 5 days - OR 2.20 (95% CI 1.36-3 ,57).

Important data on the danger of adverse reactions when using parenteral NSAIDs were obtained by S.-N. Chang et al. (2011) [34], who analyzed the causes of gastrointestinal bleeding in 40,635 patients in Taiwan. The use of injectable forms of ketorolac and diclofenac was associated with a significantly increased risk of this complication: OR 5.76 (95% CI 5.14–6.44) and 3.31 (95% CI 2.57–4.27), respectively.

Parenteral NSAIDs can also cause dangerous cardiovascular complications. This is demonstrated by the work of W.-Y. Shau ​​et al. (2012) [35], who assessed the effect of NSAID use on the incidence of acute myocardial infarction (AMI) in 8354 residents of Taiwan. This cohort was selected from among 13.7 million individuals prescribed NSAIDs who were included in a national database. Parenteral use of NSAIDs was reported to be associated with a higher risk of AMI than oral use: OR 3.35 (95% CI 2.5–4.47) and 1.42 (95% CI 1.29–1.56), respectively. At the same time, the highest risk of MI was observed when using injections of ketorolac and ketoprofen.

All of the above convinces of the need for careful selection of injectable forms of NSAIDs for the relief of acute pain. This should be a drug with minimal damaging effects on the skin, subcutaneous fat and muscles; has a long-lasting effect, allowing it to be used once a day (to reduce the number of injections required to control pain), and also has a favorable systemic safety profile. These drugs include meloxicam, a moderately selective COX-2 inhibitor, one of the most popular NSAIDs in developed countries of the world. The Drugs.com database indicates that in addition to the original meloxicam, there are more than 900 generics of this drug on the global pharmacological market [36].

Meloxicam is considered one of the most balanced representatives of the NSAID group in terms of effectiveness and safety. The main application point for this drug is the control of pain in chronic diseases of the joints and spine [37]. Nevertheless, meloxicam has also shown its worth in the relief of acute pain, for example, in anesthesiological practice [38]. The good therapeutic potential of meloxicam, in particular, was demonstrated by a series of RCTs where it was used as an analgesic during dental procedures [39–42].

Favorable tolerability and low risk of systemic adverse reactions when using meloxicam are confirmed by a long-term series of RCTs and observational studies. Thus, a relatively low incidence of gastrointestinal complications for meloxicam was noted in a network meta-analysis of 36 RCTs (n = 112,351), which assessed the risk of adverse events while taking selective (coxibs) and moderately selective NSAIDs. The likelihood of dangerous complications from the gastrointestinal tract while taking moderately selective NSAIDs (which includes meloxicam) did not differ significantly from the corresponding indicator for coxibs. The OR for the development of gastric or duodenal ulcers complicated by bleeding or perforation was 1.38 (95% CI 0.47–3.27), for clinically significant ulcers - 1.02 (95% CI 0.09–3.92 ), the total number of gastrointestinal ADRs was 1.04 (95% CI 0.87–1.25), interruption of therapy due to gastrointestinal disorders was 1.02 (95% CI 0.57–1.74) [43].

Meloxicam also demonstrates a relatively low risk of developing complications from the cardiovascular system and kidneys. Evidence of this is a meta-analysis of 19 RCTs, cohort studies and case-control studies, the authors of which assessed the total risk of adverse reactions from the cardiovascular system and kidneys for the most widely used NSAIDs in global clinical practice. Meloxicam showed the lowest combined risk of complications: OR was 1.14 (95% CI 1.04–1.25) [44].

The results of the pan-European SOS project, which examined the cardiovascular safety of major NSAIDs, were recently published. Scientists assessed the risk of developing AMI while taking NSAIDs, using information from 6 national databases in Holland, Italy, Germany and the UK, which included information on more than 32 million people, among whom 8.5 million were recorded from 1999 to 2011 patients receiving 28 different NSAIDs. In total, 79,553 episodes of AMI were observed while taking these drugs. To determine the risk of AMI for each case of this complication, at least 100 control cases were selected, matched by age and gender. For meloxicam the OR was 1.18 (95% CI 1.08–1.29), while for ibuprofen it was 1.24 (95% CI 1.04–1.48), etoricoxib was 1.28 (95 % CI 1.17–1.40), diclofenac – 1.31 (95% CI 1.17–1.48), ketorolac – 2.06 (95% CI 1.83–2.32) [45].

Russia has also accumulated very significant experience in using the original meloxicam for various diseases and pathological conditions. Over the past 25 years, Russian scientists have conducted 29 clinical trials of meloxicam for various diseases (n=3736), lasting from 7 days to 12 months. Moreover, more than 2/3 of the patients who took part in these studies gave a good or excellent assessment of the results of using meloxicam. The overall incidence of adverse events in patients receiving meloxicam was only 6.4% versus 30.5% in patients receiving other NSAIDs [46].

Meloxicam is widely used in European countries in the form of intravenous injections, with a single dose of 30 mg. Thus, A. Bekker et al. (2018) [38], in a review devoted to the use of meloxicam in surgical practice, provide data from 6 RCTs (n=1062), where meloxicam when administered intravenously at a dose of 30 mg demonstrated a significant advantage compared to placebo in terms of direct control of postoperative pain and in reducing the need for opioid analgesics.

Important data on the safety of parenteral meloxicam were obtained by S. Bergese et al. (2019) [47]. Participants in the RCT included 722 patients who had undergone various surgical operations (mainly orthopedic and soft tissue), who received intravenous meloxicam or placebo in the postoperative period. It should be noted that 119 patients were aged 65 years or older and had an initially reduced glomerular filtration rate (60–89 ml/min/1.73 m2). Each patient received an average of 2–3 injections. Meloxicam provided better pain control than placebo. Thus, the total dose of opioids required in the postoperative period (in morphine equivalent) was 29.8±58.02 mg for those who received meloxicam, and 39±68.08 mg for placebo (p<0.0001). At the same time, the number of adverse reactions did not differ between meloxicam and placebo; moreover, serious complications, such as infections, complications of the postoperative period and gastrointestinal complications, occurred significantly less frequently when using active therapy (in 2.6% and 5.5% patients respectively). A decrease in hemoglobin level of less than 100 g/l was noted in 7.6% and 6.6%, an increase in ALT activity ≥3 times in 1.8% and 2.4%, an increase in INR>1.5 in 0.9 % and 0.5%, respectively [47].

Meloxicam in the form of intramuscular injection also demonstrates high analgesic potential and good tolerability [48]. It should be noted that with intramuscular administration of meloxicam, the effect occurs within 1–1.5 hours, which is significantly faster than with oral administration, and lasts up to 24 hours. The advantages of this dosage form of meloxicam were shown in a large-scale study by L. Euller-Ziegler et al. (2001) [49], who evaluated the use of this drug in 68 volunteers and more than 800 patients with various rheumatic diseases. Meloxicam, when administered intramuscularly at a dose of 15 mg, achieved maximum plasma concentrations after 1.5 hours compared to 6 hours when administered orally at a similar dose. With intramuscular administration of meloxicam, no damage to muscle fibers was observed, as evidenced by an increase in the level of creatine phosphokinase (CPK). Thus, in healthy volunteers after a series of injections of meloxicam, there was no increase in the level of this enzyme. Meloxicam does not have a significant local damaging effect when used in real clinical practice. At the same time, according to a series of studies, the level of CPK increased after intramuscular injections of piroxicam by 147%, diclofenac by 922%. Very indicative are the data from a direct comparison of intramuscular administration of meloxicam and piroxicam in 211 patients with OA and rheumatoid arthritis (RA). After 7 consecutive intramuscular injections, the level of CK in the meloxicam group rose above normal in 3.8% of patients, in the piroxicam group - in 22.6% (p = 0.0001).

In 2 studies, the effectiveness of intramuscular administration of meloxicam was compared with the effect of other NSAIDs. Thus, K. Colberg et al. (1996) [50] compared the effect of meloxicam at a dose of 15 mg/day (on the 1st day IV, then orally) and diclofenac (on the 1st day IM 75 mg, then orally 100 mg/day) in 185 patients with RA. After 7 days of treatment, pain completely disappeared in 64% and 47% of patients in the meloxicam and diclofenac groups, respectively (p<0.05, advantage of meloxicam). Moderate or severe pain intensity was noted in only 8% and 12% of patients, respectively. It is important to note that in 13% of patients receiving meloxicam, complete cessation of pain was recorded within the 1st day of therapy.

The second RCT was presented by N.S. Bosch et al. (1997) [51], who compared the effect of meloxicam 15 mg/day (on day 1 IV, then orally) and piroxicam 20 mg/day (on day 1 IM, then orally) in 169 patients with acute NBS. After 1 week absence of pain was recorded in 54% and 48% of patients in the meloxicam and piroxicam groups, respectively (the differences are statistically insignificant). Moderate or severe pain persisted in 16% and 18% of patients.

Unfortunately, dosage forms of meloxicam for intravenous administration are not registered in Russia. Original meloxicam for intramuscular administration, according to the instructions, cannot be used intravenously.

Another 2 RCTs compared the results of IM and oral meloxicam. B. Combe et al. (2001) [52] assessed the effect of 2 dosage forms of meloxicam 15 mg in 346 patients with RA. Although after 7 days of therapy the treatment result did not differ significantly, the severity and rate of pain relief on the first day were higher with parenteral administration of meloxicam. In an RCT, V. Auvinet et al. (1995) [53] compared the effects of intramuscular and oral meloxicam in 113 patients with lumbar sciatica. As in the study by B. Combe et al. (2001) [52], parenteral and oral administration of meloxicam provided a significant reduction in pain intensity, but the effect of intramuscular injection occurred significantly earlier.

The good therapeutic potential of the original meloxicam for intramuscular injection is confirmed by the study of V.V. Alekseeva et al. (2004), during which this drug was used in 767 patients with chronic LBP, 88.4% had lumbodynia, and 11.6% had signs of radiculopathy [54]. During the first 3 days, meloxicam was administered as an intramuscular injection, then switched to oral administration of this drug. The duration of treatment depended on the characteristics of the disease and averaged 3–4 weeks. According to the data obtained, the reduction in pain intensity in lumbodynia averaged 36.1%, and in radiculopathy - 35.7%. The vast majority of patients (78.0%) rated the effect of meloxicam as good or excellent. There are also several studies that have studied paravertebral administration of meloxicam (which can be considered an IM option) for chronic LBP. The results of these studies showed good therapeutic potential and excellent tolerability of this drug [55, 56].

New data on the effectiveness of the original meloxicam for intramuscular injection were obtained in 2 studies conducted in recent years. During the first of them (CARAMBOL study), 2078 patients with acute NBS received meloxicam at a dose of 15 mg/day for up to 2 weeks, and 86.1% of them in the first 3 days - in the form of intramuscular injections, and then orally, whereas oral meloxicam alone was prescribed to only 13.9% of patients. The main criterion for assessing effectiveness was complete pain relief, which was achieved in 75.2% of patients in an average of 8.6 ± 5.5 days of using meloxicam (Fig. 1) [57].

The second study (RAPTOR) evaluated the results of analgesia with the use of the original meloxicam in 1115 patients who suffered acute injuries: radial fracture, meniscal and anterior cruciate ligament injuries of the knee, and ankle ligament injuries. In this study, all patients received NSAIDs, 93% of patients received the original meloxicam. At the same time, 43.3% of patients received intramuscular drugs during the first days, and then switched to oral administration. The use of NSAIDs, including meloxicam, allowed us to achieve a statistically significant reduction in the severity of pain at rest and during movement (in both cases p<0.001) compared to the baseline (Fig. 2) [58].

In the CARAMBOL and RAPTOR studies, during which a total of 2272 patients received meloxicam for intramuscular injection, there were not a single case of post-injection complications. We additionally searched the Internet (PubMed, Medline, Google) to identify descriptions of serious local AEs caused by IM meloxicam injections. During the search, we were unable to identify any mention of the development of complications such as abscess, sepsis, Nicolau syndrome, nerve damage and severe hematomas after intramuscular administration of this drug.

Hyaluronic acid

It is also called a “synovial fluid prosthesis”, since hyaluronic acid acts as a lubricant that protects the joint from injury. It normalizes the composition of the synovium, which becomes denser and more viscous. Hyaluronic acid perfectly relieves pain and inflammation, activates the processes of self-regeneration of cartilage. Its most common use is in patients with arthrosis. With this remedy, injections are often made into the hip joint and knees. The standard course of treatment consists of 3-5 procedures with a week interval between them. The effect lasts for a long time, up to 1 year. The most frequently prescribed drugs with “natural lubrication” are Gialgan, Hi-Flex, Gialsin.

What is the reason for failure in pain treatment?

Due to the lack of specialized training in pain management, even among oncologists, and due to the perception of cancer as an incurable disease, even medical specialists often do not realize that cancer pain can be managed.

In 80–90% of patients, pain can be completely eliminated, and in the rest, its intensity can be significantly reduced. To do this, the doctor needs to take into account each of the sources and mechanisms of pain to select adequate pain therapy for cancer.

In clinical practice, we constantly encounter typical errors in the treatment of pain: unreasonably early prescription of narcotic analgesics, use of excessive dosages of drugs, non-compliance with the prescription regimen of analgesics.

Carbon dioxide (carboxytherapy)

The effect of carboxytherapy is based on the property of carbon dioxide to cause oxygen starvation in tissues. Gas injections are given through a special device, and after the injection the body strives to enrich the joint with oxygen, increasing its blood supply. Metabolism accelerates sharply, and much more nutrients are supplied to damaged structures. In a matter of minutes, carbon dioxide leaves the joint cavity, and the effect remains for a long time.

Attention! The advantage of this unique technique is the absence of side effects, since CO2 is a natural element, a product of metabolic processes.

Carbon dioxide treatment was developed by Czech specialists from the city of Karlovy Vary, where the famous sanatorium is located. It has been successfully treating diseases of the musculoskeletal system for more than a century.

In what cases is Tramadol prohibited?

The use of analgesics in all forms is excluded in case of individual intolerance to the active and auxiliary substances, alcohol abuse or poisoning, or dependence on psychoactive substances. Other contraindications:

• suicidal tendencies, severe clinical depression;
• renal and liver failure;
• undergoing treatment with certain psychotropic drugs;
• epilepsy that cannot be corrected with medications;
• first trimester of pregnancy.

In late pregnancy and lactation, Tramadol is prescribed in exceptional cases for individual indications.

PRP therapy

PRP stands for platelet-rich plasma. Platrlet rich plasma. Platelets are responsible for the formation of blood clots - blood clots that can clog damaged blood vessels. Platelets also actively participate in the processes of cleansing wounds of unnecessary proteins and stimulate the activity of fibroblasts. The latter are responsible for the production of collagen and elastin, which are the basis of connective tissue.

PRP therapy is injections for joint pain that have a number of advantages:

• do not cause allergies or side effects;
• rarely lead to the development of complications; (hormones);
• vitamins;
• do not transmit infection..

These advantages are due to the use of the patient’s own blood, which is completely compatible with body tissues. To improve the effect, plasma administration can be combined with hyaluronic acid preparations.

How to relieve pain: a description of the stages of a three-step scheme

Low pain therapy

The patient is prescribed non-opioid analgesics: NSAIDs (Ibuprofen, Diclofenac, Ketoprofen, etc.), Paracetamol. When choosing a drug, the toxicity to the liver and kidneys inherent in all non-opioid analgesics, as well as the gastric toxicity of non-selective NSAIDs, and the risks from the cardiovascular system when using selective NSAIDs are taken into account. It is advisable to accompany the use of first-line drugs with adjuvant and symptomatic therapy: ion pump blockers, corticosteroids, antispasmodics, benzodiazepines, antihistamines, etc.

Therapy for “moderate” pain

The oral route of drug administration is preferred if the patient can take the drugs by mouth. For patients with mild to moderate pain in whom adequate pain control is not achieved by regular oral paracetamol or non-steroidal anti-inflammatory drugs, the addition of an opioid analgesic may provide effective pain relief without adverse side effects. As an alternative, low-dose opioid analgesics (eg, morphine, TTC fentanyl) may be used.

Therapy for “severe” pain

If the pain is intense and an opioid analgesic in combination with NSAIDs or Paracetamol is ineffective, therapy with strong opioid analgesics should be started. If they were prescribed for moderate pain, you need to increase the dose of the drug until it is effective. Registered prolonged forms of strong opioid analgesics in our country and used in our clinic are: morphine in capsules and tablets, TTC fentanyl.

Book a consultation 24 hours a day

+7+7+78

Advantages

• The drugs dissolve very slowly, up to 12 months.
• They have a local effect on all joint tissues.
• Almost do not enter the systemic circulation and do not affect the functioning of internal organs.
• Thanks to the previous point, they can be used in patients with severe concomitant pathologies, when treatment with other methods is unacceptable.
• Intra-articular injections help avoid surgery.
• After the procedure, no rehabilitation is required; the doctor can only apply a tight bandage and warn against excessive physical exertion.

How often does cancer pain occur?

Pain occurs in 30% of cancer patients who receive treatment and in 60–90% of patients due to disease progression. The main sources of cancer pain:

• cancer itself (45–90%);
• concomitant inflammatory reactions leading to spasm of smooth muscles (11–25%);
• pain in the area of ​​the postoperative wound after surgery (5–16%);
• concomitant pathology, for example, joint damage, arthritis (6–11%), neuralgia (5–15%).

Cancer pain syndromes are grouped:

• According to the origin of the pain flow: visceral, somatic, neuropathic, psychogenic.
• According to qualitative subjective assessment: burning, stabbing, cutting, drilling, pulsating.
• By intensity: assessed using special scales.
• Duration: acute and chronic.
• By localization: abdominal, cardialgia, lumbodynia, muscle-articular and others.

Due to significant differences in the mechanisms of pain, there is no universal analgesic to relieve all types of pain syndromes. Treatment should always be individualized.

Get rid of pain

Indications

• osteoarthritis;
• arthritis;
• bursitis;
• synovitis;
• tendinitis.

Joint diseases are very common, especially among older people. If you are one of them, or the time has come to repeat the course of treatment, call us. Our center employs high-level specialists with extensive experience, making patients feel comfortable and confident. If necessary, you will be prescribed one or more intra-articular injection procedures and a drug will be selected based on the indications.

Indications for therapeutic blockade

• pain in the neck, back;
• osteochondrosis;
• neuralgia, neuritis;
• pain in the spine due to intervertebral hernia;
• rheumatism;
• osteoarthritis;
• pain in the postoperative period;
• phantom pain;
• Minière's syndrome;
• neuropathy;
• spasticity;
• amputation pain;
• pain and spasticity after a stroke;
• radiculitis;
• migraine;
• sciatica;
• tunnel syndrome.

How to use Tramadol: instructions

The drug is prescribed by a doctor in short courses as a symptomatic remedy. The regimen of use and dosage depend on the physical condition and age of the patients.

• Instructions for oral solution: patients over 14 years old - 20 drops with a spoon of sugar or water, 1 time per day. If necessary, it is allowed to repeat the dose after 1–2 hours. Children under 14 years of age: at the rate of 1 mg. per 1 kg. body weight.
• Tablets and capsules are taken with water, before or after meals. Daily dose: 50 mg. For severe pain, an increase to 400 mg is possible.
• Tramadol injections are given subcutaneously, intravenously or intramuscularly. Before administration, the contents of the ampoules are diluted in saline solution. Daily doses of the drug vary from 50 to 400 mg. Time intervals between injections: 4–6 hours.
• Suppositories are used rectally, introducing 1 piece. from 1 to 4 times a day.

Elderly people suffering from reduced liver or kidney function are recommended to reduce the dose of Tramadol by half.