228 Chapter 7 Pain Assessment and Management in Children
Table 7-6
Coanalgesic Adjuvant Drugs
DRUG DOSAGE INDICATIONS COMMENTS ANTIDEPRESSANTS Amitriptyline 0.2-0.5 mg/kg PO hs Continuous neuropathic pain with Provides analgesia by blocking reuptake of serotonin Titrate upward by 0.25 mg/kg every 5-7 days prn burning, aching, dysthesia with and norepinephrine, possibly slowing Available in 10- and 25-mg tablets insomnia transmission of pain signals Usual starting dose: 10-25 mg Helps with pain related to insomnia and depression (use nortriptyline if patient is oversedated) Analgesic effects seen earlier than antidepressant effects Nortriptyline 0.2-1.0 mg/kg PO AM or bid Neuropathic pain as above without Side effects include dry mouth, constipation, urinary Titrate up by 0.5 mg every 5-7 days insomnia retention. Maximum: 25 mg/dose ANTICONVULSANTS Gabapentin 5 mg/kg PO at bedtime Neuropathic pain Mechanism of action unknown Increase to bid on day 2, tid on day 3 Side effects include sedation, ataxia, nystagmus, Maximum: 300 mg/day dizziness Carbamazepine 6 yr: Sharp, lancinating neuropathic pain Similar analgesic effect to amitriptyline 2.5-5 mg/kg PO bid initially Peripheral neuropathies Monitor blood levels for toxicity only Increase 20 mg/kg/24 hr, divide bid every week prn Phantom limb pain Side effects include decreased blood counts, ataxia, Maximum: 100 mg bid gastrointestinal irritation 6 to 12 years: 5 mg/kg PO bid initially Increase 10 mg/kg/24 hr divide bid every week prn to usual max: 100 mg/dose bid 12 years: 200 mg PO bid initially Increase 200 mg/24 hr, divide bid every week prn to max: 1.6-2.4 g/24 hr ANXIOLYTICS Lorazapam 0.03-0.1 mg/kg every 4-6 hr PO or IV Muscle spasm May increase sedation in combination with opioids Maximum: 2 mg/dose Anxiety Can cause depression with prolonged use Diazapam 0.1-0.3 mg/kg every 4-6 hr PO or IV Maximum: 10 mg/dose CORTICOSTEROIDS Dexamethasone Dose dependent on clinical situation; higher bolus Pain from increased intracranial Side effects include edema, gastrointestinal irritation, doses in cord compression, then lower daily dose pressure increased weight, acne Try to wean to NSAIDs if pain allows Bony metastasis Use gastroprotectants such as H2-blockers Cerebral edema: 1-2 mg/kg load then 1-1.5 Spinal or nerve compression (ranitidine) or proton pump inhibitors such as mg/kg/day divided every 6 hr omeprazole for long-term administration of Maximum: 4 mg/dose steroids or NSAIDs in end-stage cancer with Antiinflammatory: 0.08-0.3 mg/kg/day divided bony pain every 6-12 hr OTHERS Clonidine 2-4 mcg/kg PO every 4-6 hr Neuropathic pain 2-Adenoreceptor agonist modulates ascending pain May also use a 100 mcg transdermal patch every 7 Lancinating, sharp, electrical, sensations days for patients 40 kg (88 lb) shooting pain Routes of administration: oral, transdermal, and Phantom limb pain spinal Management of withdrawal symptoms Monitor for orthostatic hypertension, decreased heart rate Sedation common Mexiletine 2-3 mg/kg/dose PO tid, may titrate Similar to lidocaine, longer acting 0.5 mg/kg every 2-3 wk prn Stabilizes sodium conduction in nerve cells, reduces Maximum: 300 mg/dose neuronal firing Can enhance action of opioids, antidepressants, anticonvulsants Side effects include dizziness, ataxia, nausea, vomiting May measure blood levels for toxicity bid, Twice a day; IV, intravenous; NSAIDs, nonsteroidal antiinflammatory drugs; PO, by mouth; prn, as needed; tid, three times a day.