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Dr Vidya Viswanath

Asst Professor , Palliative Care

Homi Bhabha Cancer Hospital
&Research Centre, Visakhapatnam
A substance that helps and enhances the
effect of a drug, treatment or a biological
 ‘Any drug that has a primary indication
other than pain, but is an analgesic in
some painful conditions’
 In combination with an analgesic they enhance
pain control
 Have independent analgesic activity for certain
pain types (such as neuropathic pain)
 May counteract the side effects of NSAIDs or
 Effect on pain is circumstance specific
 Co – Analgesic
• Administered with a primary analgesic
• To enhance pain relief
• To treat pain refractoruy to the analgesic
• To reduce the analgesic dose for limiting side
NOTE: Other Adjuvant drugs are co administered
with analgesics for treating side effects
produced by analgesic or managing symptoms
other than pain
 Comprehensive Assessment – For drug
 Positioning of Treatment- Optimise with
opioids and then adding is recommended
 Pharmacological characteristics
 Interindividual and Intraindividual
 Risks and benefits of polypharmacy
Multipurpose adjuvant analgesics
• Antidepressants
• Corticosteroids
• Alpha – 2 adrenergic agonists

Topical analgesics
• Capsaicin
• Local anaesthestics
• Tricyclic Antidepressants
 Adjuvant analgesics used for bone pain
• Calcitonin and Bisphosphonates
Adjuvant Analgesics for bowel obstruction
Adjuvant analgesics for Musculoskeletal pain
Adjuvant analgesics for Neuropathic pain
 Patientwith oral cancer complaining of burning
radiating along the cheek till the head

 Patient
with Ca Cervix bending over
complaining of severe pain radiating down to
the legs

 Patient
with diabetes with pricking pain in the
hands and soles
Occurs in 10-30% of zoster

( up to 50% in elderly >

Peripheral Central:
• Ischemic
• Metabolic/nutritional
(DM, thyroid, b12) • Tumor
• Entrapment • Infectious
• Connective tissue (encephalitis)
disorders (vasculitis, RA) • Inflammatory
• Toxins ( chemo) (vaculitis)

• Infectious (HIV) • Degenerative

• Malignancy
Tricyclic antidepressants
Serotonin and Noradrenaline reuptake inhibitors – SNRI
s- Venlafaxine, Duloxetine

Gabapentin, Pregabalin, Carbamazepine, valproate

Topical Agents
Capsaicin, Lidocaine patch, EMLA
 Oral Sodium Channel Blockers
Mexiletine, Tocainide, Flecainide

Alpha -2 adrenergic agonists

Clonidine, Tizanidine

N- Methyl – D – Aspartate receptor antagonists

Dextromethorphan, ketamine

GABA agonists
Tricyclics and
SNRI block the
cholinergic ,
and sodium
channels, inhibit
serotonin and
Amitriptyline 10-25 50-150 Drowsiness,
Nortriptyline mg/day mg/day confusion,
Desipramine Increase
hypotension, dry
Imipramine weekly mouth,
by 10 constipation,
mg/day urinary retention,
weight gain,
arrhythmia ,
Caution in the
 Dampen electrical signals
 in the central nervous system

 Better for lancinating or

 paroxysmal pain

 They mimic GABA and bind the 2- subunit

of calcium channels, reducing influx of
Calcium in neuronal cells. This decreases
the release of glutamate, norepinephrine
and Substance P at the synapses
 Can take a few days to get the benefit
 Starting dose is low and gradually
 Side effects: drowsiness, loss of muscle
coordination (ataxia) or blurring of vision

 Not a silver wand !!

Starting dose
Usual maintenance
Agent and titration dose

Gabapentin 300 mg/day; increase 300-1200 mg

weekly by 300 mg/day
three times
Pregabalin 75-100 mg/day; 150-300 mg
increase weekly by
50-150 mg/day twice daily

Carbamazepine 100 mg once daily; 200-400 mg

increase weekly by
100-200 mg/day three times
Valproate 200mg hs, increased daily
to 800mg
Drug Management of Neuropathic Pain

TCA and AC


Palliative Formulary Choosing the Adjuvant analgesic for neuropathic pain
Peripheral and spinal non opioid sites
of action of analgesics
 Patient
with liver metastases complaining of
severe right hypochondrial pain

 Patient
with breast cancer complaining of
severe headache and vomiting due to brain

 Patient
with lung cancer complaining of severe
back ache , losing balance and incontinence
 Reduces peritumour oedema
 Reduces inflammation
 High initial dose trial reduced and tapered to the
minimum dose to control the symptom
 Controls pain till other measures take over – like
radiotherapy and anti depressants
 First line in the neuropathic ladder
 Can improve appetite, QOL and relieve nausea

 Side effects include neuropsychiatric syndromes,

gastrointestinal disturbances and
 Dose – Dexamethasone 4-8 mg oral or
parenteral in liver capsular stretch pain
 Dexa 16-32 mg/day in increased ICT . PCM
with the steroids

 Dose equivalence
 Dexamethasone Oral/SC/IV 2mg =
Prednisolone Oral/Rectal 15mg =
Hydrocortisone Oral/IV 60 mg=
Methylprednisolone Oral/IV 12 mg
 Patientwith ovarian cancer and now in
complete bowel obstruction complaining
of colicky abdominal pain

 Renal colic
Use antispasmodics for muscle spasm

 Hyoscine butylbromide (Buscopan)

• Adults: start at 10mg three times a day; can be
increased to 40mg three times a day

 Antispasmodics can cause nausea, dry mouth,

or constipation
 Patient
with breast cancer on treatment
with multiple skeletal metastases

 Multiple Myeloma
 Potent inhibitors of osteoclast- mediated bone
 Useful for reducing the incidence of fractures in
bone metastases

 Pamidronate, Zolendronate – Intravenous

 Ibandronate,Clodronate, Alendronate orally

 Side effects :Flu like syndrome, Osteonecrosis of the

A young lady with pancreatic cancer on
opioids with a back muscle spasm

A young adult female with metastases in

the lung, dyspnoea and severe anxiety
Skeletal muscle spasm and anxiety-related pain
•Diazepam : Adults 5mg orally bd or tid
•Baclofen : 5mg tid

• 0.5-2mg oral or intravenous every 3 to 6 hours
Can cause drowsiness and ataxia

Clonazepam : In neuropathic pain with an added element

of anxiety and muscle spasm
A 17 year old with Ewings Sarcoma on
chemotherapy with severe pain in the
back, radiating down to the legs, foot
drop, incontinence

A 45 year old with lung cancer and

severe pain on the left rib pain getting
drowsy with opioids and inadequate pain
 Combination of opioids, NSAIDs ,
Paracetamol, Neuropathic pain
medicines, anxiolytics

 Would need Dexamethasone initially and

then taper and switch to NSAIDs

 Antibiotics
 Antiemetics
 Laxatives
 Gastroprotective Drugs
 Neuroleptics like Olanzipine can potentiate the
effects of opioids

 Drug interactions : Some eg

 Prokinetic and anti secretory
 Ranitidine and Gefitinib
Thank you
Pallium India
Homi Bhabha Cancer
Hospital &
Research Centre
All my teachers
All our patients and