neurologic disorders
Treatment of Pain
Nonopioid Analgesics
 and nonsteroidal anti-inflammatory drugs (NSAIDs) are often effective for mild to moderate pain (see table Nonopioid Analgesics ). These drugs are given orally; Acetaminophenhas no anti-inflammatory or antiplatelet effects and does not cause gastric irritation. Aspirinis the least expensive NSAID, but it has irreversible antiplatelet effects and increases the risk of gastrointestinal (GI) bleeding. NSAIDs have analgesic, anti-inflammatory, and antiplatelet effects. They inhibit cyclooxygenase (COX) enzymes and thus decrease production of prostaglandins. There are several classes of NSAIDs, which have different mechanisms and adverse effects: Nonselective COX inhibitors (eg,ibuprofen,naproxen) Selective COX-2 inhibitors (coxibs; eg,celecoxib) Both COX inhibitors are effective analgesics. Coxibs have the lowest risk of ulcer formation and GI upset. However, when a coxib is used with low-doseaspirin, it may have no GI benefit over other NSAIDs. Studies suggest that inhibition of COX-2, which occurs with both nonselective COX inhibitors and coxibs, has a prothrombotic effect that can increase risk of myocardial infarction, stroke, and claudication. This effect appears to vary by specific drug, as well as by dose and duration. Some evidence suggests the risk is very low with some of nonselective COX inhibitors (eg,ibuprofen,naproxen, coxibs [celecoxib]). However, clinicians should consider the potential for prothrombotic effects as a risk with all NSAIDs; thus, all NSAIDs should be used cautiously in patients with clinically significant atherosclerosis or multiple cardiovascular risk factors. If an NSAID is likely to be used only short term, significant adverse effects are unlikely, regardless of the drug used. Some clinicians use a coxib first whenever therapy is likely to be long term (eg, months) because the risk of GI adverse effects is lower. Others limit coxib use to patients predisposed to GI adverse effects (eg, older patients, patients taking corticosteroids, those with a history of peptic ulcer disease or GI upset with other NSAIDs) and to those who are not doing well with nonselective NSAIDs or who have a history of intolerance to them. All NSAIDs should be used cautiously in patients with renal insufficiency; coxibs are not renal-sparing. If initial recommended doses provide inadequate analgesia, a higher dose is given, up to the conventional safe maximum dose. If analgesia remains inadequate, the drug should be stopped. If pain is not severe, another NSAID may be tried because response varies from drug to drug. It is prudent during long-term NSAID therapy to monitor for occult blood in stool and changes in the complete blood count (CBC), electrolytes, and hepatic and renal function. Topical NSAIDsmay be applied directly to the painful region for disorders such as osteoarthritis and minor sprains, strains, and contusions. A 1.5% solution ofdiclofenachas been shown to effectively treat pain and limited joint function caused by osteoarthritis of the knees; dose is 40 drops (1.2 mL) applied 4 times a day to each affected knee. Other topicaldiclofenacformulations that may be useful for local pain relief include a patch (applied 2 times a day over the affected area) or a 1% gel (2 g 4 times a day for the upper extremities or 4 g 4 times a day for the lower extremities). 