Paracetamol - not first line for chronic osteoarthritis or back pain
NSAIDs
- Main stay for MSK pain with an inflammatory component.
- Can by synergistic with opioids
TCA/SNRI - NNT of 3.5 - 6.5 for one person to experience 50% reduction in pain
- Primarily noradrenaline effect working on reduced re-uptake of noradrenaline from the post-synaptic region leading to up-regulation of descending inhibitory pathways
- Need to get to a reasonable dose, and be on it for at least 2-4 weeks to have neuroprotective proteins created
- Ceasing should be done through tapering the dose over 2-4 weeks
(interestingly authors suggest using fluoxetine 10 mg as well when discontinuing over 2-4 weeks - this is new to me!)
TCA
- Often the antihistaminergic side effects such as sleep initiation and maintenance can be helpful
- Start low and go slow
(Nortriptyline - 10 mg/day orally increasing weekly in 10-25 mg up to 75-150mg - over 4-6 wks)
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