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Are you in pain? Identifying & Treating Pain in Patients with Dementia
Gregory Harochawtache@mts.net
Disclosure
• I have been paid from time to time to speak from:▫ Purdue Pharma▫ Janzen▫ Pfizer▫ Valeant
• None of this presentation was funded
Objectives
• Ways of identifying pain with someone who cannot verbally express their pain
• Use of alternate treatment options
Common Problems (Especially in residential or nursing homes)
• Tendency to normalize pain. ▫ i.e. We become older so aching/soreness is seen as
an everyday discomfort
• One of the most common symptoms for people with dementia experience is pain that is poorly diagnosed/undertreated
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
http://www.scie.org.uk/publications/dementia/endoflife/pain.asp
Common Problems • Pain is an individual experience that different
people feel in different ways• People with dementia are less likely to report
pain through normal auditory communication. As dementia progresses:▫ Speech ability may decline poor
communication▫ Inability to understand questions▫ Need prompting to take pain meds
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Common problems• People with advanced dementia this is a
common symptom• People with dementia experience pain just like
everyone else• Pain is often poorly recognised/undertreated
not difficult to treat• Some people think that people with dementia do
not experience pain or that their memory is so poor that they forget the experience
http://www.scie.org.uk/publications/dementia/endoflife/pain.asp
Common Problems
• National UK statistics pain is under-treated and under-recognized in older people▫ 65 years old 50% reported pain/discomfort▫ 75 years + 56% men, 65% women▫ Institutionalized people, 45 – 83% reported at
least one current pain problem
http://www.bgs.org.uk/Publications/Clinical%20Guidelines/pain%20concise%20guidelines%20WEB.pdf
Common Problems• Myth:▫ Stronger analgesics (opioids) must be avoided as
they can add to confusion and make the dementia worse
• Opioid medications can cause confusion if given too high of a starting dose or one titrates the dose too fast
• The greater amount of pain someone is in, generally the higher the dose they can tolerate without a lot of side effects
http://web.missouri.edu/proste/tool/cog/AJN-Pain-Assess-108.7.2008.pdf
Do pain killers confusion in people with dementia?• 181 participants, long-term stay, patients:▫ Severe dementia did not experience less pain
intensity▫ Severely demented patients receiving opioids
demonstrated higher pain intensity than non-demented patients
▫ Patients with mixed dementia receiving opioids had more pain then mentally healthy controls & they received less pain treatment
http://www.mendeley.com/catalog/suffers-most-dementia-pain-nursing-home-patients-cross-sectional-study/
Common causes of pain in people with dementia• Sitting/lying down in one position with
uncomfortable/tight clothes/shoes can lead to pressure sores
• Weight loss associated with dementia ill-fitting dentures & sore gums
• People with teeth decay/abscesses improper cleaning
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Common causes of pain in people with dementia• Osteoarthritis• Pressure sores• Skin tears• Leg ulcer dressings• Stiffening of joints• Changing wound dressings
• Muscle rigidity• Constipation• Urinary tract infections• Movement pain▫ i.e. helping someone turn in
bed, get dressed/undressed
http://www.scie.org.uk/publications/dementia/endoflife/pain.asp
Consequences of not treating pain
• Unnecessary suffering/distress• Inadequate Tx pain ▫ Problematic behaviours▫ Inappropriate Rxs of sedatives/tranquilisers
• Pain functional ability, worsen memory or delay recovery after surgery
• Interfere with sleep depression/social withdrawal
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
“To leave a person in avoidable pain and suffering should be regarded as a serious
breach of fundamental human rights [and] can be regarded not only as unethical, but also as
negligence.”
-Margaret Somerville
Proceedings of the 7th World Congress on Pain, 1994
What is pain?“Unpleasant sensory and emotional experience
associated with actual or potential tissue damage”
“Pain is what the person says hurts. No other person can experience the pain, know what it feels like or how it really affects the person physically &
emotionally”
International Association for the Study of Pain 1994
International Association of Hospice and Palliative Care
Detecting someone in pain
• Dementia DOES NOT alter the fundamental experience of pain
• Social/cultural factors should be considered▫ Use interpreters if person doesn’t speak English as
their 1st language▫ Relatives/close care givers may notice subtle
changes
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Observational Changes Associated with Pain
• Autonomic changes▫ Pallor, sweating, tachypnea, altered breathing
patterns, tachycardia, hypertension• Facial expressions▫ Grimacing, wincing, frowning, rapid blinking,
brow raising/lowering, cheek raising, eyelid tightening, nose wrinkling, lip corner pulling, chin raising, lip puckering
• Mental status change▫ Confusion, crying, distress, irritability
http://www.bgs.org.uk/Publications/Clinical%20Guidelines/pain%20concise%20guidelines%20WEB.pdf
Observational Changes Associated with Pain• Body movements▫ Altered gait, pacing, rocking, hand wringing,
repetitive movements, increased tone, guarding, bracing
• Verbalisations/vocalisations▫ Aggression, withdrawal, resisting
• Changes in activity patterns▫ Wandering, altered sleep, altered rest patterns
http://www.bgs.org.uk/Publications/Clinical%20Guidelines/pain%20concise%20guidelines%20WEB.pdf
Ways of expressing pain
• Behavioural changes▫ Fidgeting, restlessness, repetitive behaviours,
pacing or wandering▫ May become tense or on edge when physical care
is about to be given pushing away of care givers or angry if they cannot verbally express pain that will be experienced
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Ways of expressing pain• Mood changes▫ Depression & withdrawal
• Facial expressions▫ Frowning, sad, grimacing, tense, frightened
• Body language▫ Guarding, bracing, rubbing or holding the painful
part of the body• Speech▫ Shouting out repeatedly, screaming, crying or
groaning
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Ways of expressing pain• Signs on physical examination▫ Pressure sores, tears in the skin, arthritis or
deformities in the joints▫ Changes blood pressure, pulse rate, sweating,
pallor, noisy or laboured breathing▫ Food refusal/loss of appetite▫ Changes in mobility or walking gait▫ Constipation, retention of urine distended
abdomen
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
How to communicate with Someone who can’t speak• Someone who can no longer speak in
words/sentences still DO communicate• Ability to communicate in one-syllable words
such as “Yes” or “No”▫ Exceptions: Final stage dementia Suffered a stroke or similar condition that may have
affected their speech circuitry
http://www.dementiacareaustralia.com/index.php
How to communicate with Someone who can’t speak• “Yes” or “No” answer can be given:▫ Saying the words out loud▫ Shaking or nodding of head▫ Using facial expressions Looking up & making eye contact; smiling or looking
down for a “Yes” Looking straight into space or giving no reaction at
all for a “No”
http://www.dementiacareaustralia.com/index.php
How to communicate with Someone who can’t speak• Research shows words are not our only means
of communicating a message▫ Words: makes up 7%▫ Tone of voice: makes up 38% and▫ Body language: which makes up 55%
• 93% of our communication is non-verbal• Word/sentence through our tone of voice & look
on our face completely opposite meaning
http://www.dementiacareaustralia.com/index.php
How to communicate with Someone who can’t speak• Be a good listener▫ Help someone who can’t put words or sentences
together make sense of what is going on inside his/her mind & to express it
• Ask yourself:▫ What is the person attempting to communicate?▫ What is the need that is not fulfilled?
http://www.dementiacareaustralia.com/index.php
How to communicate with Someone who can’t speak
• Intuition▫ Use your intuition as a guide to help you guess at
what the person is attempting to communicate▫ Intuition is our ability to take information &
process it in relation to what we have learned previously/experienced
▫ Gives us our initial response to a question▫ Is incredibly fast as we use both of our
hemispheres in our brain
http://www.dementiacareaustralia.com/index.php
How to communicate with Someone who can’t speak• Intuition▫ Once we have guessed what the person is
attempting to communicate we need to acknowledge the need or feeling that is being expressed check this “guessed” need or feeling of the person
▫ People with dementia do know how they feel & what their needs are but simply express them differently
http://www.dementiacareaustralia.com/index.php
Diagnosing Pain• Use simple “yes/no” questions when asking person
about their pain do not overload the person by asking repeated questions or the person may become agitated/distressed
• Try other words:▫ “ache” and “hurt”, “Is it sore?”▫ “Does it hurt a lot?” or “How much?” may not be
helpful as the person may not be able to describe how bad the pain is or how often it occurs
• Ask the person directly provide information on their pain
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Diagnosing pain
• Non-verbal communication▫ Ask to point to affected part▫ Use of pictures
• Caregivers need to work hard to understand a person’s verbal/non-verbal signs of being in pain
Diagnosing pain
• Pain not obvious thorough physical examination by doctor/nurse taking cues from patient’s facial expression/posture
• Referring to another health provider:▫ Occupational therapist/physiotherapist may be
helpful with musculoskeletal problems▫ Nurse for care of ulcers/pressure areas
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Treating pain in dementia• Assessment▫ Done on regular/systemic basis to minimize pain
• Acknowledging person is in pain▫ Reassure person and act on information given▫ Explain what you are doing to help them even
though you don’t think they understand you• Treat cause▫ Pressure cushions/mattresses, repositioning,
relieve of constipation, loosen clothing, regular dental check ups
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Treating pain in dementia
• Comfort▫ Heat/ice packs for joint problems▫ Massage for tension/muscle spasms▫ Immobilising/splinting limbs may discomfort
associated with chronic fractures/arthritis
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Abbey Pain Scale
• For measurement of pain in people with dementia who cannot verbalize
• Australian Pain Society recommends that this scale is to be used as a movement-based assessment▫ Observe & record while resident is being moved i.e. during pressure area care, while showering, etc.
Abbey Pain Scale
• Pain scale is part of an overall pain management plan
• Pain management requires ongoing assessment • Scale does not differentiate between distress &
pain measure effectiveness of pain-relieving interventions is essential
Abbey Pain Scale• Complete the scale immediately following
procedure & record results in resident’s notes• Include:▫ Time of completion of scale & score▫ Staff member’s signature & action (if any) taken in
response to results of assessment i.e. pain medication or other therapies
• 2nd evaluation done 1 hour after any intervention taken in response to 1st assessment to see if Tx effective
Abbey Pain Scale
• Score on pain scale is the same or worse, undertake a comprehensive assessment and monitor closely over 24 hour period including any interventions undertaken
• No improvement notify practitioner
1 Australian Pain Society(2005) Residential Aged Care Pain Management Guidelines, August. http://www.apsoc.org.au 1 Gibson, S., Scherer ,S and Goucke , R (2004) Final Report Australian Pain Society and the Australian Pain Relief Association Pain Management Guidelines for Residential Care: Stage 1Preliminary field-testing and preparations for implementation. November
Abbey Pain Scale1. Vocalization:▫ Whimpering, groaning, cryingAbsent 0 Mild 1 Moderate 2 Severe 3
2. Facial Expression: ▫ Looking tense, frowning, grimacing, looking frightenedAbsent 0 Mild 1 Moderate 2 Severe 3
3. Change in body language:▫ Fidgeting, rocking, guarding part of body, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3
http://prc.coh.org/PainNOA/Abbey_Tool.pdf
Abbey Pain Scale4. Behavioural change: ▫ confusion, refusing to eat, alteration in usual patterns
Absent 0 Mild 1 Moderate 2 Severe 35. Physiological change: ▫ Temperature, pulse/blood pressure outside normal limits,
perspiring, flushing or pallorAbsent 0 Mild 1 Moderate 2 Severe 3
6. Physical changes: ▫ Skin tears, pressure areas, arthritis, contractures,
previous injuriesAbsent 0 Mild 1 Moderate Severe 3
http://prc.coh.org/PainNOA/Abbey_Tool.pdf
Abbey Pain Scale
• Add scores 1 6
• Check box which matches type of pain
0 – 2 3 – 7 8 – 13 14 +
No pain Mild Moderate Severe
Chronic Acute Acute on chronic
Abbey Pain Scale
• Conceptual blurring between acute and chronic pain with no discussion on distinguishing characteristics of pain types
• Physiological indicators is not supported in the literature on chronic pain
• Validity testing is based on nurse judgement of pain severity and is not substantiated in the literature
http://prc.coh.org/PainNOA/ABBEY_B.pdf
Pain Assessment in Advanced Dementia (PAINAD) ScaleItems 0 1 2 Score
Breathingindependent of vocalization
Normal Occasional labouredbreathing. Short period of hyperventilation
Noisy laboured breathing. Long period of hyperventalation. Cheyne-Stokes respirations
Negative vocalization
None Occasional moan or groan.Low level speech with negative or disapproving quality.
Repeated troubled calling out. Loud moaning or groaning. Crying
Facial expression
Smiling or inexpressive
Sad. Frightened. Frown Facial grimacing
Body language Relaxed Tense. Distressed pacing. Fidgeting.
Rigid. Fists clenched. Kneespulled up. Pulling or pushing away. Striking out.
Consolability No need to console
Distracted or reassured by voice or touch.
Unable to console, distract or reassure.
Total
http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf
PAINAD Scale
• Total score ranges from 0 – 10 points
Score Rating
1 – 3 Mild pain
4 – 6 Moderate pain
7 – 10 Severe pain
http://www.healthcare.uiowa.edu/igec/tools/pain/PAINAD.pdf
NON-OPIOID
ASAAcetaminophen
NSAID+/- adjuvant
OPIOID FOR MILD TO MODERATE PAIN
CodeineOxycodoneTramadol
Tapentadol
+/- non-opioid+/- adjuvant
OPIOID FOR MODERATE TO SEVERE PAIN
OxycodoneHydromorphone
Morphine-------------------------------------------
FentanylMethadone
+/- non-opioid+/- adjuvant
WHO Analgesic Ladder
Pain 1 - 3
Pain 4 - 6
Pain 7 - 10
Approaches to reducing pain
• Timely warnings▫ Warn resident before a potentially painful
movement/action▫ Allow resident to prepare for movement/action▫ Wait for resident to provide permission (if able)
before performing task
Talerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74
Approaches to reducing pain
• Movement in bed▫ Don’t pull on arms when rolling/moving. Grasp
shoulders/hips using a “log-roll” technique to keep body in proper alignment
▫ Draw sheets to roll patient from side to side rather pulling or pushing on various parts of the body
Talerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74
Approaches to reducing pain• Transferring▫ Insufficient body strength raise the head of the bed
and help resident onto his/her side before bringing to a sitting position
▫ Don’t pull on the resident’s neck when moving/transferring
▫ Allow resident time at the edge of the bed to get his/her bearings before completing transfer
▫ Raise electric beds high enough that legs are bent at the knee at a slightly more than 90° to assist in coming to standing position
▫ Brace painful knees during transfersTalerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74
Approaches to reducing pain
• Seating and positioning▫ Get an individualized wheelchair assessment from
physical or occupational therapist▫ Ensure foot rests are fitted to resident▫ Pad areas of wheelchair that cause pressure▫ Adjust tilt-in-space wheelchair Q1-2H to relieve
pressure & change position
Talerico KA, et al. Alzheimer’s Care Quarterly 2006;7(3):163-74
Treating pain
• Simple pain killers▫ Acetaminophen/NSAID mild to moderate pain▫ Acetaminophen dose 3 – 4 grams/day ▫ NSAID 26% of people Tx require anti-ulcer Rx
• Chronic pain Tx regular dosing to prevent pain from occurring▫ Long-acting medications tend to give better
coverage
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Treating Pain• Stronger painkillers▫ Opioids useful moderate to severe pain ▫ SE’s constipation & confusion but this should
not stop them from being prescribed• Consider stopping some medical treatments ▫ Some Txs may make little contribution to person’s
health but can cause pain & QOL painful blood tests Invasive physical investigations
http://www.pssru.ac.uk/pdf/MCpdfs/Pain_factsheet.pdf
Opioids• Opioids should be started at a lower dose (25-
50%) of a younger person due to pharmacokinetics/pharmacodynamic changes
• Opioids in elderly people▫ Meperidinemetabolite can cause
neuroexcitation, nervousness & seizures▫ Tramadol caution with SSRI medications▫ Codeine great variability in it’s effectiveness. Up
to 30% of the population are poor metabolizers of codeine
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546472/
Equipotent Doses of OpioidsOpioid Oral Dose IM/IV/SC Dose
Morphine 10mg 3-5mgCodeine 100mg 50-60mgFentanyl - 0.25mg
Hydromorphone 2mg 1mgOxycodone 5mg 2-3mgMethadone 1-10mg -Meperidine 150mg 35-40mgTapentadol 25mg -Tramadol 50mg -
Transdermal ConversionDaily PO
morphine doseBuprenorphine patch
strengthFentanyl patch
strengthBreakthrough PO
morphine dose12mg daily 5ug/hr - 2mg hourly PRN24mg daily 10ug/hr - 4mg hourly PRN
30 – 59mg daily 12ug/hr 5 – 7.5mg hourly PRN
60 – 90mg daily 25ug/hr 10 – 15mg hourly PRN
Alternate Routes• Development of alternate method(s) of drug
administration allows to manage specific problem(s) or an alternate way of introducing systemic medication
• Look at the following alternate routes:▫ Transmucosal Sublingual & intranasal
▫ Topical
Transmuccosal:Anatomic & Physiologic Factors Factors
• Buccal mucosa is crisscrossed by a large network of blood and lymphatic vessels.
• Drugs administered by this route are quickly absorbed into the systemic circulation rapid onset
• Avoidance of gastric proteases, hepatic 1st-bypass and intestinal metabolism
Care Beyond Cure 4th Edition
Transmuccosal:Limiting Factors and Disadvantages• Taste of formulation may be unpalatable• Ideal volume < 0.5ml; if more than 1-2 ml is
administered, then some of the solution will be swallowed
• Excessive salivation may lead too rapid dissolution & absorption of drugs unstable at gastric pH
• Route may be compromised if integrity of mucosa altered (mucositis)
Care Beyond Cure 4th Edition
Transmucosal:Required Conditions & Method of Administration
• Unsweetened concentrated solutions ideal▫ Keeps volume < 0.5ml▫ Reduces chance of nausea▫ Sweetened solutions saliva production
• Patient’s mouth is dry, place a few drops of water under the tongue to hydrate & help dissolve medication
• Try not to swallow/chew for about 10 minutes (if possible) to allow complete absorption
Care Beyond Cure 4th Edition
Transmucosal Treatment of Pain• Absorption after 10 minutes▫ Fentanyl 51%▫ Hydromorphone 25%▫ Morphine 22%
• Fentanyl S/L Incident pain▫ Onset 5 -10 minutes▫ Peak effect 15 – 30 minutes▫ Duration of analgesia 30 – 40 minutes▫ NB* Patient needs to be instructed not to swallow
doseCare Beyond Cure 4th Edition
Medical Care of the Dying 4th Edition
Intranasal:General Principles• Most intranasal (IN) use is off label• Nasal cavity easily accessible, rich vascular
plexus permits topically administered drugs to achieve rapid blood levels while avoiding intravenous catheters
• Most effective when distributing drug solutions as a mist rather than large droplets which may aggregate & run off instead of being absorbed
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:General Principles• Emerging as a promising method of delivering
medications directly into blood stream due to easy access to a vascular bed
• Method of delivery can eliminate the need for intravenous catheters while still achieving rapid, effective blood levels of the medication administered
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:Advantages1. Rich vascular plexus of the nasal cavity
provides a direct route into the blood stream for medications that easily cross mucous membranes
2. Avoids GI destruction & hepatic 1st – bypass allowing more drug to be cost-effectively, rapidly and predictably bioavialable than if given PO
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:Advantages3. IN medications absorption rates and plasma
concentrations are comparable to IV administration and typically are better than SC or IM routes
4. Easy, convenient and safe to use. Essentially painless and does not require a sterile technique & is immediately & readily available for all patients
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
IntranasalAdvantages5. Nasal mucosa is near the brain, cerebral spinal
fluid drug concentrations can exceed plasma concentrations. IN administration may rapidly achieve therapeutic brain & CNS drug concentrations
IN medication delivery is simply another option or method to deliver medication
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:Limiting Factors & Disadvantages• Limited medications that can be delivered • Many medications are not adequately
concentrated to achieve ideal dosing volumes• Mucosal health impacts absorption▫ Bloody nose or large volumes of mucous
production will wash medication contact with mucosa
▫ Destroyed mucosa will have blood flow absorption i.e. topical use of vasoconstrictors
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:Required Conditions & Method of Administration• Ideal volume per nostril is 0.25 – 0.3ml▫ Some clinicians use as much as 1ml per nostril &
accept runoff and drug loss at this higher volume• The larger the nasal mucosa surface area that is
covered, the more medication that can be absorbed
• Ideal drug dose is divided in ½ and each nostril receive the ½ dose
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal:Required Conditions & Method of Administration• Significant difference in drug distribution is
observed with drops, nebulizer, atomized pump, pressurized aerosol, etc.
• Multiple studies show atomized pump is the best nasal delivery system as it gives a constant dose & very good mucosal distribution▫ Ideal particle size 10 – 20µm are deposited on
nasal mucosa and not inhaled
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal: Dosing• Doses are usually less than PO meds but higher
than IV • Therapeutic effect is achieved in 3-5 minutes &
peaking at 10-15 minutes▫ Dose larger than 1ml split dose & deliver @ 10-15
minute intervals• Due to delayed rising of drug levels, respiratory
depression will rarely happen ▫ Exception sufentanil due to high potency
Therapeutic Intranasal Drug Delivery http://intranasal.net/Overview/default.htm
Intranasal: MAD Device(Mucosal Atomizing Device)
Use a luer lock syringeWorks in any positionSemipermeable soft plus absorbs runoffDead space 0.09ml Wolfe Tory Medical
Intranasal Drugs & Dosing
Drugs used and dosing go to:Therapeutic Intranasal Drug Delivery:
Needleless treatment options for medical problemshttp://intranasal.net/Home/default.htm
Reasons for Topical Route• Oral route not desirable• More localized action ▫ Transdermal us can provide up to 30 fold higher
drug concentration than PO• Most sites produce in systemic blood levels
and chance of drug interactions• Avoids the GI tract and hepatic first-pass
metabolism
Topical Treatment of Neuropathic Pain – IJPC Vol 12 No 3
Reasons for Topical Route
• Can reduce systemic side effects as different sites have different systemic absorption▫ Apply to knee about 5% systemic absorption▫ Apply to thigh, mid-section & upper arms about
20% systemic absorption Oxybutynin 10% Transdermal: 100mg applies OD ≈
PO 5mg IR tablets - TID▫ Apply to inner wrist or behind ear systemic
levels similar to SC levels
• Possible irritation at application site• Drying of the skin with transdermal products• Variations in the stratum corneum barrier
variable absorption▫ May need to add penetration enhancers
• Need to concentrate dosage form to accommodate therapeutic response
• Rate of absorption may vary
Heir, Gary DMD, et al. IJPC 2004; 8:337-343
Topical Route: Drawbacks
Transdermal• Greg’s 5 R’s▫ Right volume Need to saturate area 1ml to knee
▫ Right concentration▫ Right penetration depth Can add penetration enhancer like DMSO 2.5 – 20%
to allow drug(s) to reach site of action▫ Right length of time to rub product into area▫ Right combination
Site Permeability
• Generalized rank order of site permeabilities:▫ genitals > head/neck > trunk > arm > leg▫ Preterm infant > term infant > young adult
> elderly
Klein & collegues,. Transdermal Clonidine Therapy in Elderly Mild Hypertensives; Hypertension Suppl 1985:3;581-584
□ Ketamine __5% __10% __15%(requires a triplicate Rx with this Rx)
□ Gabapentin __6% __8% __10%□ Clonidine __0.1% __0.2%□ Lidocaine __2% __ 5% __ 7.5%□ Tetracaine __ 2% __ 5% __ 7.5%□ Loperamide __5% __10%□ Morphine __ 0.5% __ 1% __ 2%□ Ketoprofen __5% __10% __20%□ Diclofenac __2% __4% __5%□ Carbamazepine __2% __5%□ Baclofen __2% __5%□ Amitriptyline __2% __5%□ Guaifenesin __5% __10%
DMSO ____ 5% ____ 10% ____ 20% Other: ____ %
Transdermal• Shingles▫ Ketamine 10-15%, morphine 1-5%, gabapentin
6-10%, tetracaine 2-5% in Lipoderm®• Lower back pain▫ Diclofenac 8%, DMSO 5%, baclofen 2-5%,
tetracaine 2-5% in Lipoderm®• Joint pain▫ Diclofenac 10%, DMSO 20%, tetracaine 5% ▫ Ketorolac 8%, DMSO 20%, tetracaine 5%
Both in Lipoderm®
ABHR Topical Gel
• Lorazepam 2mg/diphenhydramine 50mg/ haloperidol 2mg/metoclopramide 40mg/ml
• Lorazepam 4mg/diphenhyramine 100mg/ haloperidol 4mg/metoclopramide 80mg/ml▫ Applied 0.25-0.5ml QID PRN ▫ To inner part of wrist
Rectal FissuresNifedipine ____ 0.2% ____0.3% ____ 0.5%
ONLY USE 1 OF THESE 3Diltiazem ____ 2%
Nitroglycerin ____ 0.1% ____ 0.2% ____0.4% ____0.6%
Lidocaine ____ 1% ____ 2%
Hydrocortisone ____ 1% ____ 2%
Other: _____ %
All products will be in Vaseline as a base unless otherwise specified
Other base:
Mitte: ________ gm
Sig: Apply to the affected area 2 to 3 times daily and after a bowel movement
OR: ________________________________________________________________
Refill: ____________
Recommended