Update on Musculoskeletal Pain Management

Tsai, André Wan Wen; Kobayashi, Ricardo; Liu, Ibrahim Afrânio Willi; Fim, Márcio; Liggieri, André Cicone; Machado, Edilson Silva

doi:10.1055/s-0043-1776135

André Wan Wen Tsai Address for correspondence Andre Tsai, MD, PhD, Colégio Médico de Acupuntura do Estado de SP, Rua Alves Guimarães, 855, apt 62, Pinheiros, CEP 05410-001, São Paulo, Brazil (e-mail: tsai.andre@gmail.com).

Colégio Médico de Acupuntura do Estado de SP, São Paulo, SP, Brazil

https://orcid.org/0000-0003-1867-7004

Ricardo Kobayashi

Pain Center, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil

Ibrahim Afrânio Willi Liu

Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

https://orcid.org/0000-0001-7740-3770

Márcio Fim

Elbow and Shoulder Surgery, Instituto de Previdência dos Servidores do Estado de Minas Gerais (IPSEMG), Belo Horizonte, MG, Brazil

https://orcid.org/0000-0002-5526-8755

André Cicone Liggieri

Pain Center, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil

Edilson Silva Machado

Pain and Palliative Care Service, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil

https://orcid.org/0000-0002-0332-572X

Address for correspondence Andre Tsai, MD, PhD, Colégio Médico de Acupuntura do Estado de SP, Rua Alves Guimarães, 855, apt 62, Pinheiros, CEP 05410-001, São Paulo, Brazil (e-mail: tsai.andre@gmail.com).

Conflicts of Interest

The authors declare no conflict of interests.

		Initial dose	Posology	Therapeutic dose	Notes
Simple analgesic agents
Dipyrone (metamizole)		500 mg to 1 g	6/6 hours	Up to 4 g/day	Agranulocytosis risk²⁴24 Sakata RK, Nunes MHG. Analgesics use for kidney failure. Rev Dor 2014;15(03):224–229
Paracetamol		500 to 750 mg	6/6 hours	Up to 3 g/day	Hepatotoxicity²³23 Hamerschlak N, Maluf E, Biasi Cavalcanti A, et al. Incidence and risk factors for agranulocytosis in Latin American countries–the Latin Study: a multicenter study. Eur J Clin Pharmacol 2008;64 (09):921–929
Non-steroidal anti-inflammatory drugs: recommended for acute pain in minimal doses and for short courses
Non-selective		Variable	Variable	Variable	Gastrointestinal and renal effects²⁸28 Kraychete DC, Siqueira JTT, Zakka TRM, Garcia JBS. Recommendations for the use of opioids in Brazil: Part III. Use in special situations (postoperative pain, musculoskeletal pain, neuropathic pain, gestation and lactation). Rev Dor 2014;15(02): 126–132
Cox-2 selective		Variable	Variable	Variable	Cardiovascular effects³²32 Lee CR, McTavish D, Sorkin EM. Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs 1993;46 (02):313–340
*Opioid analgesic agent (per os)*
Weak	Codeine	15 to 30 mg	Up to 6/6 hours	Variable Maximum dose: 360 mg/day	Dose-dependent: euphoria, nausea, obstipation, addiction, sedation, and respiratory depression³⁶36 Kobayashi R, Luzo MVM, Cohen M. Tratado de dor musculoesquelética. São Paulo: Alef; 2019
Weak	Tramadol	50 to 100 mg	Up to 4/4 hours	Variable Maximum dose: 400 mg/day
Strong	Morphine	5 to 30 mg	Up to 4/4 hours	Variable No maximum dose
	Oxycodone	10 mg	12/12 hours	Variable No maximum dose
	Methadone	2.5 to 5 mg	Up to 4/4 hours	Variable No maximum dose
	Buprenorphine	5 mg	Every 7 days	Variable No maximum dose
Antispasmodic muscle relaxant agents
Carisoprodol		350 mg	Up to 6/6 hours	Maximum dose: 1.400 mg/day	Postural hypotension, drowsiness, and dizziness⁴⁵45 Sabatschus I, Bösl I, Prevoo M, et al. Comparative Benefit-Risk Assessment for Lidocaine 700 mg Medicated Plaster and Pregabalin in Peripheral Neuropathic Pain Following a Structured Framework Approach. Pain Ther 2022;11(01):73–91
Cyclobenzaprine		5 mg a 10 mg	Up to 8/8 hours	20 to 40 mg Maximum dose: 60 mg/day	Drowsiness, dizziness, and dry mouth⁴⁶46 Menezes MS, Sakata RK, Issy AM. Anticonvulsivantes. In: Sakata RK, Issy AM, editores. Fármacos para tratamento da dor. Barueri, SP: Manole; 2008:111–138

		Initial dose	Posology	Therapeutic dose	Adverse effects
*Antidepressant agents*
Tricyclic	Amitriptyline Imipramine Nortriptyline	10 to 25 mg	Once per day, 3 hours before sleeping	25 to 150 mg/day	Drowsiness, dizziness, tremors, headaches, postural hypotension, dry mouth, nausea, constipation, weight gain, decreased libido, hyperhidrosis, urinary retention, and suicidal ideation⁴⁷47 Ben-Menachem E. Pregabalin pharmacology and its relevance to clinical practice. Epilepsia 2004;45(Suppl 6):13–18
Dual	Duloxetine	30 mg	Once a day, in the morning	60 to 120 mg/day	Nausea, dry mouth, drowsiness, increased blood pressure, and suicidal ideation⁴⁸48 Gammaitoni AR, Alvarez NA, Galer BS. Pharmacokinetics and safety of continuously applied lidocaine patches 5%. Am J Health Syst Pharm 2002;59(22):2215–2220
Dual	Venlafaxine	37.5 to 75 mg	Once a day, in the morning	150 to 225 mg/day
*Anticonvulsant agents*
Gabapentin (GBP)		300 mg	8/8 hours	1,200 to 3,600 mg/day	Dizziness, nausea, drowsiness, edema of extremities, weight gain, blurred vision, and suicidal ideation⁴⁸48 Gammaitoni AR, Alvarez NA, Galer BS. Pharmacokinetics and safety of continuously applied lidocaine patches 5%. Am J Health Syst Pharm 2002;59(22):2215–2220
Pregabalin (PGL)		50 to 75 mg	12/12 hours	150 to 600 mg/day
Topical
5% lidocaine patch		1 to 3 patches	12 hours without the patch/12 hours with the patch	1 to 3 patches

		Initial dose	Posology	Therapeutic dose	Notes
Simple analgesic agents
Dipyrone (metimazole)		500 mg to 1 g	6/6 hours	Up to 4 g/day	Agranulocytosis risk²⁴24 Sakata RK, Nunes MHG. Analgesics use for kidney failure. Rev Dor 2014;15(03):224–229
Paracetamol		500 to 750 mg	6/6 hours	Up to 3 g/day	Hepatotoxicity²³23 Hamerschlak N, Maluf E, Biasi Cavalcanti A, et al. Incidence and risk factors for agranulocytosis in Latin American countries–the Latin Study: a multicenter study. Eur J Clin Pharmacol 2008;64 (09):921–929
Non-steroidal anti-inflammatory drugs: recommended for acute pain in minimal doses and for short courses
Non-selective		Variable	Variable	Variable	Gastrointestinal and renal effects²⁸28 Kraychete DC, Siqueira JTT, Zakka TRM, Garcia JBS. Recommendations for the use of opioids in Brazil: Part III. Use in special situations (postoperative pain, musculoskeletal pain, neuropathic pain, gestation and lactation). Rev Dor 2014;15(02): 126–132
Cox-2 selective		Variable	Variable	Variable	Cardiovascular effects³²32 Lee CR, McTavish D, Sorkin EM. Tramadol. A preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in acute and chronic pain states. Drugs 1993;46 (02):313–340
Opioid analgesic agent (per os)
Weak	Codeine	15 to 30 mg	Up to 6/6 hours	Variable Maximum dose: 360 mg/day	Dose-dependent: euphoria, nausea, obstipation, addiction, sedation, and respiratory depression³⁶36 Kobayashi R, Luzo MVM, Cohen M. Tratado de dor musculoesquelética. São Paulo: Alef; 2019
Weak	Tramadol	50 to 100 mg	Up to 4/4 hours	Variable Maximum dose: 400 mg/day
Strong	Morphine	5 to 30 mg	Up to 4/4 hours	Variable No maximum dose
	Oxycodone	10 mg	12/12 hours	Variable No maximum dose
	Methadone	2.5 to 5 mg	Up to 4/4 hours	Variable No maximum dose
	Buprenorphine	5 to 40 mg	Every 3 or 7 days	Variable No maximum dose
	Tapentadol	50 to 250 mg	12/12 hours	500 mg/day
Antispasmodic muscle relaxant agents
Carisoprodol	350 mg	Up to 6/6 hours	Maximum dose: 1.400 mg/day	Postural hypotension, drowsiness, and dizziness⁴⁵45 Sabatschus I, Bösl I, Prevoo M, et al. Comparative Benefit-Risk Assessment for Lidocaine 700 mg Medicated Plaster and Pregabalin in Peripheral Neuropathic Pain Following a Structured Framework Approach. Pain Ther 2022;11(01):73–91
Cyclobenzaprine	5 mg a 10 mg	Up to 8/8 hours	20 to 40 mg Maximum dose: 60 mg/day	Drowsiness, dizziness, and dry mouth⁴⁶46 Menezes MS, Sakata RK, Issy AM. Anticonvulsivantes. In: Sakata RK, Issy AM, editores. Fármacos para tratamento da dor. Barueri, SP: Manole; 2008:111–138

[1] Address for correspondence Andre Tsai, MD, PhD, Colégio Médico de Acupuntura do Estado de SP, Rua Alves Guimarães, 855, apt 62, Pinheiros, CEP 05410-001, São Paulo, Brazil (e-mail: tsai.andre@gmail.com).

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Update on Musculoskeletal Pain Management

Abstract