Chapter 161. Other Adjuvant Agents Commonly Used in Pain Management Lucia Daiana Voiculescu, MD; Amit Poonia, MD View Full Chapter Figures Only Tables Only Videos Only Print Share Email Twitter Facebook Linkedin Reddit Get Citation Citation AMA Citation Voiculescu L, Poonia A. Voiculescu L, Poonia A Voiculescu, Lucia Daiana, and Amit Poonia.Chapter 161. Other Adjuvant Agents Commonly Used in Pain Management. In: Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta.eds. The Anesthesia Guide New York, NY: McGraw-Hill; 2013. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572§ionid=42543751. Accessed September 20, 2018. MLA Citation Voiculescu L, Poonia A. Voiculescu L, Poonia A Voiculescu, Lucia Daiana, and Amit Poonia.. "Chapter 161. Other Adjuvant Agents Commonly Used in Pain Management." The Anesthesia Guide Atchabahian A, Gupta R. Atchabahian A, Gupta R Eds. Arthur Atchabahian, and Ruchir Gupta. New York, NY: McGraw-Hill, 2013, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=572§ionid=42543751. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Mendeley © Copyright Tools Search Book Top Return Clip Autosuggest Results ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintVarious Adjuvant Agents Used for Pain ManagementDrug/principal mechanism of actionPain indicationsCommon dosing1Common side effectsSpecial considerationsTramadolDual mechanism: serotonin/norepinephrine reuptake inhibitionWeak mu-opioid receptor agonismAcute and chronic pain: moderate–severe1Postoperative pain2Neuropathic pain250–100 mg po q6–8 hNausea, vomiting, constipation, dizziness, headachesSerious reactions: seizures, serotonin syndromeCaution if history/risk of seizureAvoid abrupt cessationRisk of suicidalityPregnancy Class CClonidineCentral alpha-2 adrenergic agonistPeripheral neuropathy2Postherpetic neuralgia2Cancer pain2CRPS2Postoperative pain2Adjuvant in neuraxial and peripheral nerve blocks2Opioid withdrawal20.1 mg po q12 h weekly titration up to 2.4 mg/day0.1 mg/day transdermalUp to 0.6 mg/day30 μg/h epidural infusionHypotension, bradycardia, AV block, dry mouth, drowsiness, sedation fatigue, depression, feverAvoid abrupt withdrawal, risk of rebound hypertensionPregnancy Class CKetamineNMDA receptor antagonismIntraoperative and postoperative pain2Burn pain2Cancer pain2Neuropathic pain2Opioid-induced hyperalgesia2IV infusionTransdermalSQ infusionIn analgesic doses: hypersalivation, anorexia, nausea, elevated BP, hallucinations, withdrawal syndrome (long-term use)Black box warnings: emergence reactions—various degrees of psychologic manifestations from pleasant dream-like states to irrational behavior and emergence delirium. The 100 mg/mL concentration of ketamine hydrochloride injection should not be injected intravenously without proper dilutionPregnancy Class DLidocaineBlocks sodium channelsDecreases ionic flux through the neuronal membranePostherpetic neuralgia1Local anesthesia, postoperative pain1Neuropathic pain2Burn pain2Topical: transdermalmaximum three patches/ 24 hIV: various protocolsPregnancy Class C1FDA approved.2Off-label usage for neuropathic pain. ++Table Graphic Jump LocationFavorite Table | Download (.pdf) | PrintMuscle Relaxant Agents Commonly Used in Pain ManagementDrug/principal mechanism of actionPain indicationsCommon dosing1Common side effectsSpecial considerationsBaclofenGABA-B agonistSpasticity2Myofascial pain3Trigeminal neuralgia3GERD3Oral: start at 5 mg TIDMaximum 80 mg/dayIntrathecal: for severe spasticityDrowsiness, weakness, fatigue, hypotension, constipation, nauseaBlack box warnings (for the intrathecal administration): avoid abrupt cessation—high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity after abrupt D/CPregnancy Class CBenzodiazepines:DiazepamClonazepamGABA-B agonistDiazepam:Muscle spasmAcute postoperative myofascial pain3Clonazepam:NeuralgiaPeriodic leg movementSpasticity3Diazepam:2–10 mg po q6–8 h5–10 mg IM/IV4q3–4 h prnClonazepam:0.5–4 mg po q8 hDrowsiness, dizziness, impaired coordination, amnesia, confusion, somnolence, irritabilitySignificant dependence, abuse and addiction potential associated with chronic benzodiazepine administrationPregnancy Class DTizanidineCentral alpha-2 adrenergic agonistSpasticity2Muscle spasm and pain3Acute pain3Chronic headache32–8 mg TIDDrowsiness, dry mouth, somnolence, asthenia, hypotension, bradycardiaAdditive effects with alcohol and other CNS depressantsReduced clearance with oral contraceptivesPregnancy Class CCyclobenzaprineCentrally acting muscle relaxantMuscle spasm and pain2Fibromyalgia3TMJ disorder35–10 mg po ... GET ACCESS TO THIS RESOURCE Sign In Username or Email Please enter User Name Password Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. What is MyAccess? Create a FREE MyAccess profile to: Use this site remotely Bookmark your favorite content Track your self-assessment progress and more! GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessAnesthesiology 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessAnesthesiology Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options Pop-up div Successfully Displayed This div only appears when the trigger link is hovered over. Otherwise it is hidden from view. Please Wait