SEKILAS

PENATALAKSA
NAAN NYERI
Dr. AWALUDDIN NOOR, Sp.S

Prima Resort Kuningan

9 April 2010

Definisi Nyeri (Pain) dari

IASP
(International Association for the Study of Pain)

Pain (Nyeri) adalah suatu

pengalaman sensorik dan
emosional yang berkaitan
dengan kerusakan
jaringan atau diduga ada
kerusakan jaringan

Nyeri adalah

pengalaman sensorik
yang berkaitan
dengan aktivasi
nociceptor dan
lintasan nyeri
Nyeri adalah suatu
pengalaman
emosional
Kerusakan jaringan
tidak mesti ada

JENIS NYERI
Neuropathic Pain

Mixed Pain

Pain initiated or caused by a

primary lesion or dysfunction
in the nervous system
(either peripheral or
central nervous system)1

Pain with
neuropathic and
nociceptive
components

Examples
Peripheral
Post herpetic neuralgia
Trigeminal neuralgia
Diabetic peripheral neuropathy
Postsurgical neuropathy
Posttraumatic neuropathy
Central
Posts troke pain
Common descriptors2
Burning
Tingling
Hypersensitivity to touch or cold

Inflammatory Pain
Pain caused by injury to
body tissues
(musculoskeletal,
cutaneous or visceral)2

Examples

Examples

Low back pain with

radiculopathy
Cervical
radiculopathy
Cancer pain
Carpal tunnel
syndrome

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57

Pain due to inflammation

Limb pain after a fracture
Joint pain in osteoarthritis
Postoperative visceral pain

Common descriptors2
Aching
Sharp
Throbbing

Neuropathic Pain is
Different from
Muscle/skeletal
Pain
Neuropathic Pain
Muscle/skeletal Pain
Chronic pain (months/years)

Acute pain (hours or days)

Caused by injury or disease to nerves Caused by injury or inflammation that

affects both the muscles and joints
Mild to excruciating pain that can last
indefinitely

Moderate to severe pain that

disappears when the injury heals

Causes extreme sensitivity to touch

simply wearing light clothing is
painful

Causes sore, achy muscles

Sufferers can become depressed or

socially withdrawn because they see
no relief in sight and may experience
sleep problems

Sufferers can become anxious and

distressed but optimistic about relief
from pain

Wall PD. Textbook of Pain. 4th ed; 1999; Jude EB. Clin in Pod Med and Surg.1999;16:81-97;
Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997: Goldman L.
Cecil Textbook of Medicine. 21st ed; 2000

Symptoms of Neuropathic Pain

Characterized Differently
Neuropathic Pain

Muscle/Skeletal Pain

Price SA. Pathophysiology: Clinical Concepts of Disease Processes. 5th ed; 1997; Galer BS et
al. Diabetes Res Clin Pract. 2000;47:123-128

Neurophatic
pain

Nociceptive/
imflammatory/
musculoskletal
pain

Thick, myelinated, fast

conducting neurons
Mediate the feeling of initial
fast, sharp, highly localized
pain.

Rabaan
Tekanan

Very thin, unmyelinated, slowconducting

Mediate slow, dull, more
diffuse, often burning pain.

Nerve Fibers
Class

Velocity

Function

A-

Fast

Motor

A-

Fast

A-

Intermediate

Touch,
pressure
Muscle tone

A-

Intermediate

Pain,
temperature

Small

Motor

Small

Pain

Targets of Pain Therapies

Pharmacotherapy
Non-opioid analgesics
Opioid analgesics
Nerve Blocks
Adjuvant analgesics (neuropathic,
musculoskeletal)

tramadol

Electrical Stimulation

Acetaminofen

Transcutaneous electrical nerve

stimulation (TENS)
Percutaneous electrical nerve
stimulation (PENS)

Alternative methods
(NSAID)
Gottschalketal.,2001

Acupuncture
Physical Therapy
Chiropractics
Surgery

ABC Tx. Nyeri

Anamnesa nyeri secara sistematik dan

teratur
Berpikiran positif (percaya) terhadap
keluhan pasien atau keluarga
Carilah metode kontrol nyeri yang nyaman
untuk pasien dan keluarga
Dilakukan intervensi yang tepat waktunya,
logis dan terkoordinasi
Edukasi pasien dan keluarga untuk
mengatasi nyeri sekuat mungkin

Analgesics
Non-opioid analgesics (non-opioids):
paracetamol, acetylsalicylic acid, metamizole* and
nonsteroidal anti-inflammatory drugs (NSAIDs).

Opioid analgesics (opioids):

weak opioids (codeine, dihydrocodeine,

tramadol) and strong opioids (i.e., morphine).

Papaver somniferum

Co-analgesics: a diverse group of drugs, with primary

indications for conditions other than pain, with analgesic
properties relevant to some conditions. Commonly used
adjuvant analgesics include antiepileptic drugs (AEDs), tricyclic
antidepressants (TCAs) and local anaesthetics (LAs).

Diagnosis

Drug Treatment

Acute and chronic pain

NSAIDS , Opioids (al tramadol),

Paracetamol

Myofascial pain
dysfunction

Analgesics , tricyclics,
centrally-acting muscle
relaxants, glucocorticoids

Neuropathic pain,
neuralgias

Carbamazepine, phenytoin,
baclofen, tricyclics,
gabapentin, others?

Acetaminophen
May inhibit COX selectively in central nervous

system
Only weak inhibitor of peripheral COX (peroxide
effects?)
Inhibits effects of substance P in CNS?
Inhibits effects of glutamate in CNS?

Paracetamol
1.

2.
3.

4.

Paracetamol is an effective analgesic for acute pain

(Level I*).
Paracetamol is an effective adjunct to opioids (Level I).
NSAIDs given in addition to paracetamol improve
analgesia (Level I).
IV paracetamol is an effective analgesic after surgery
(Level II), is as effective as ketorolac (Level II) and
equivalent to morphine after dental surgery with better
tolerance (Level II).

Mekanisme Kerja Tramadol

Dua mekanisme kerja yang saling melengkapi:

1. Kerja di opioid:
- Agonis reseptor
- Metabolit aktif
(O-desmethyltramadol/M1)

2. Kerja di monoaminergic:
Menghambat re-uptake
serotonin/noradrenalin

Mekanisme Kerja Tramadol

Tramadol
Menuju Otak

Descending pathway

Neuron dari saluran spinothalamic

Serotonin/Noradrenalin
-Receptor

2-Receptor

Tramadol

Transmiter nyeri

Spinal neuron

Rangsang Nyeri

Enkephalin

PAIN PHARMACOTHERAPHY

Choose drugs based on:

mechanism of pain
safety and pharmacology of aging
match pain severity with drug potency
use combined drug and non-drug strategies
Use adequate dose; appropriate route
Anticipate, prevent and manage side effects

Rationale for a fixed-dose

combination analgesic
Enhanced analgesia
Reduced doses of components - fewer side effects
Rapid onset of action and lasting duration
Broad spectrum of efficacy in terms of indications
and pain intensity
Higher patient compliance and ease of
administration

Fixed drug combinations ( ZALDIAR)

Fixed combinations are appropriate for on-demand treatment
typically used in acute pain conditions and situations of non-stable
pain or intermittent pain in chronic conditions.
A fixed analgesic combination simplifies drug delivery without the
need for complicated dose-escalating regimens and, therefore,
improves compliance.

Free drug combinations

Free drug combinations are particularly appropriate for the
management of stable chronic pain syndromes.
The main advantage of free drug combinations is that they allow the
dose regimen to be tailored to individual requirements. On the other
hand, this may be time-consuming because it involves a gradual and
dose-escalating strategy.

Kombinasi NSAID
Kombinasi 2 NSAID:

Tidak dianjurkan
Efek samping meningkat
Tidak menambah efikasi

Kombinasi NSAID
dengan Pelindung
Lambung:
Ditujukan untuk sedikit
mengatasi masalah efek
samping terhadap
lambung.
Dapat diberikan bersama
golongan PPI,
Misoprostol

Kombinasi NSAID dan

Analgetik (paracetamol)
Masih dapat
dipertanggungjawabkan

ZALDIAR
(37,5 MG TRAMADOL PLUS 325 MG PARASETAMOL)

PHAROS INDONESIA

Komposisi :
37.5 mg Tramadol plus 325 mg Taracetamol

Indikasi

Mengurangi nyeri sedang sampai berat

Sediaan

Tablet salut film

Kemasan :
Box isi 10 tablet
Harga 1 box : Rp 65.000
Harga 1 tablet Rp 6.500

INDIKASI ZALDIAR
Nyeri sedang sampai berat seperti :

Nyeri Pasca Operasi

Trauma karena
kecelakaan
Low-back pain

Bedah minor

Rehabilitasi pasca
cedera olahraga

Nyeri Osteoarthritis
Tambahan pengobatan
pada OA/RA yang telah
diberi NSAID/COX-2

Dosis Untuk Dewasa (>12

Tahun)

Dosis ZALDIAR fleksibel tergantung dari

intensitas nyeri.
Untuk nyeri yang berat dosis awal bisa
2 tablet kemudian diberikan setiap 6 jam

Rata-rata dosis per hari 3-4 tablet

Maksimal 8 tablet per hari

(Sama dengan 300 mg tramadol/2600 mg parasetamol)

ZALDIAR: Onset cepat durasi

lama
Pain relief probabilities

Tramadol/paracetamol

Paracetamol
1

Tramadol
0
0

10

Waktu (jam)

Kerja analgesik yang saling melengkapi:

Onset cepat dari parasetamol dikombinasi dengan durasi lama dari
tramadol

Perhatian pada kelompok

pasien berikut :
ZALDIAR jangan diberikan pada:
Anak-anak <12 tahun
Selama hamil
Selama menyusui
Kategori ZALDIAR C

Kontraindikasi

Hipersensitif terhadap tramadol dan parasetamol

Acute intoxication alkohol, hypnotic, analgesik

sentral, opioids atau obat psychotropic

Pemberian bersamaan dengan MAO inhibitor or

within two weeks of withdrawal

Gangguan fungsi hati berat

Epilepsi yang tidak sedang dalam pengobatan

Peringatan
Dosis maksimal 8 tablet per hari
No concurrent use of any other products containing
paracetamol or tramadol

Tidak direkomendasikan pada pasien dengan

gangguan ginjal (creatinin clearance <10ml/mm)

Jangan diberikan pada pasien dengan gangguan

hati berat

Tidak direkomendasikan pada pasien dengan

gangguan pernafasan berat

Interaksi
Kontra indikasi / tidak direkomendasikan
digunakan bersamaan dengan:

MAO inhibitors, Alcohol,

Carbamazepine, Opioid agonistsantagonists

STUDI KLINIS

Nyeri setelah bedah mulut

(gigi)
Medve RA et al. Anesthesi Prog, 2001

Tujuan:
Membandingkan efikasi dan keamanan dari
tramadol/parasetamol (ZALDIAR) dengan tramadol atau
parasetamol monoterapi

Dosis:

Tramadol 75 mg/parasetamol 650 mg

75 mg tramadol
650 mg parasetamol
400 mg ibuprofen
Plasebo

Desain penelitian:
1200 pasien dengan nyeri sedang sampai berat

setelah bedah (cabut) gigi geraham paling belakang

(geraham bungsu) yang di random menjadi 3, double
blind, paralel group, studi dosis tunggal yang
diobservasi selama 8 jam.
Tiga pusat penelitian terdiri dari 400 pasien; yang

terdistribusi merata dalam pengobatan

Medve RA et al. Anesth Prog, 2001

Hasil penelitian: efikasi

*P .0001 vs Tramadol/paracetamol; P = .0004 vs Tramadol/paracetamol;

P .0001 vs all active treatments

TOTPAR 8 = Total pengurangan nyeri dalam 8 jam

SPID = Jumlah perbedaan intensitas nyeri dalam 8 jam

Kesimpulan penelitian
ZALDIAR pada pasien bedah
gigi
Pengurangan / penurunan intensitas nyeri dengan
ZALDIAR lebih superior dibanding tramadol atau
parasetamol sendiri atau plasebo
Mula kerja ZALDIAR lebih cepat dan durasi kerja lebih
lama dibanding tramadol atau parasetamol sendiri.
Masing-masing komponen dari ZALDIAR berkontribusi
terhadap efikasi analgesik
ZALDIAR adalah analgesik kuat dengan

onset cepat, durasi panjang yang efektif

dalam pengobatan nyeri akut

Efek samping setelah

pemberian ZALDIAR ( 5%)
Tramadol/
paracetamol
(n=240)

Tramadol
(n=238)

Paracetamol
(n=240)

Ibuprofen
(n=240)

Placebo
(n=239)

Nausea
(mual)

56 (23%)

56 (24%)

22 (9%)

23 (10%)

38 (16%)

Vomiting
(muntah)

51 (21%)

49 (21%)

17 (7%)

16 (7%)

23 (10%)

Dizzines
(pusing)

11 (5%)

12 (5%)

10 (4%)

7 (3%)

9 (4%)

Hasil penelitian: onset (mula kerja)

Hasil penelitian: durasi kerja

Pain: A conceptual approach to treatment (Biopsycosocial

approach)

Cognitive therapies
Functional restoration

Pain Behaviors
Suffering

Opioid
Adjuvants
NSAIDs?
Acetaminophene
Neural augmentation
Ablative surgery

Anti-depressants /
psychotropics
Relaxation
Spiritual

Pain
Perception

Nociception

Local block

NSAIDs (Movicox )
Surgery
Physical modalities

1. Looser JD, Cousins MJ. Med J aust 1990;216: 153-208; 2. van den Hout JH, et al. Clin J Pain. 2003;19:87-96.; 3.
Mynors-Wallis L, et al. Br J Psychiatry. 1997;170:113-119.; 4. Morley S, et al. Pain. 1999;80:1-13.

HATUR NUHUN