Update on pain management in acute pancreatitis

Abstract

Purpose of reviewThis review discusses the analgesic options available from randomized controlled trials and recent systematic reviews. The evidence from other settings is considered and the evidence specific to acute pancreatitis emphasized. This highlights the options that are best supported by evidence but also the options that warrant further clinical trials.Recent findingsNonsteroidal anti-inflammatory drugs and paracetamol can provide adequate pain relief in patients with acute pancreatitis when compared with opioids. Epidural analgesia provides optimum pain relief in the first 24 h of onset of acute pancreatitis in addition to potential improvement in pancreatic perfusion. Several experimental analgesics and acupuncture have potential as opioid sparing strategies. Opioids are needed for patients with severe pain, to which adjuvant and experimental analgesics might be added.SummaryAmong the many options for pain management, the following principles should apply:tailor treatment to the individual patient (one size will not fit all);assess both pain intensity and pancreatitis severity when selecting analgesics;a step-down approach might be required achieve prompt pain relief (especially in patients with severe acute pancreatitis);use opioid sparing strategies whenever possible (especially in patients with mild acute pancreatitis); andpatients should be enrolled in much needed clinical trials where possible.

Opioid analgesia and severity of acute pancreatitis: An international multicentre cohort study on pain management in acute pancreatitis

“…The necessity of opioid analgesia has been questioned, as adequate pain relief has been reported with non-opioid analgesia. 6,27 However, some patients will find non-opioid analgesics inadequate and require an alternative…”

“…These factors are not consistently and systematically included in the assessment of patients on admission or used to tailor treatments for improved management. The necessity of opioid analgesia has been questioned, as adequate pain relief has been reported with non‐opioid analgesia 6,27 . However, some patients will find non‐opioid analgesics inadequate and require an alternative for optimal pain relief.…”

“…The necessity of opioid analgesia has been questioned, as adequate pain relief has been reported with non‐opioid analgesia. 6 , 27 However, some patients will find non‐opioid analgesics inadequate and require an alternative for optimal pain relief. While optimal pain relief is important for mobilisation and recovery 28 there is also a concern, at least theoretically, that without it, there is an increased risk of central neuronal sensitisation and chronic pain.…”

“…Local complications were defined according to the definitions given in the RAC. 13 The analgesic modalities 6 were categorised as: � simple analgesic (e.g., paracetamol, non-steroidal antiinflammatory drugs) � weak opioid (e.g., codeine, dihydrocodeine, tramadol) � strong opioids (e.g., morphine, diamorphine, oxycodone, hydromorphone, buprenorphine, fentanyl, and tapentadol) � adjuvant analgesics (e.g., tricyclic antidepressants, gabapentin, venlafaxine, duloxetine, and antispasmodics).…”

“…5 There are many potentially harmful effects of opioids on the human gastrointestinal tract, which could influence the course and outcome of AP . [6][7][8] Opioids can cause intestinal dysmotility, ileus, and bacterial overgrowth as well as increased intestinal permeability, which in turn might increase the risk of bacterial translocation, infected pancreatic necrosis, and worsen the severity of AP. 9 Furthermore, opioid administration may contribute to immunosuppression, which may promote infections.…”