Curriculum Vitae:

dr. Laniyati Hamijoyo SpPD-KR.

M.Kes
• Staf pengajar Departemen Ilmu Penyakit Dalam FK UNPAD/
RS Hasan Sadikin Bandung

Pendidikan:
1994 : FK Universitas Atma Jaya, Jakarta
1996 : Internship di CWZ Nijmegen-Netherland
2005 : Spesialis Penyakit Dalam FK.UNPAD, Bandung
2005 : Magister kesehatan FK. UNPAD, Bandung
2007 : Subspesialisasi Reumatologi di Univ.Santo Tomas Manila
2008 : Adaptasi Konsultan Reumatologi FKUI,Jakarta

Organisasi: Anggota:
IRA, PAPDI, PRA, IDI, APLAR

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 Rationale using NSAIDs
Rationale using NSAIDs
Laniyati Hamijoyo
Laniyati Hamijoyo
Divisi Reumatologi Departemen Ilmu Penyakit Dalam
Divisi Reumatologi Departemen Ilmu Penyakit Dalam
FK Universitas Padjadjaran/ RS Hasan Sadikin Bandung
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FK Universitas Padjadjaran/ RS Hasan Sadikin Bandung
 Outline the essentials of pain

1 Definition of pain

Mechanism of pain
2

3 Assessment pain

4 Rationale NSAIDs

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 Pain

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 Patients’ Demography &
Pain Prevalence

86% of patients who came to medical 64% of patients are ≥ 40 years old.
practice suffered pain

41%

14% 36%

Have Pain 23%

No Pain

86%

< 40 y.o 40 - 59 y.o >60 y.o

Total Respondent = 9322 patients who came

to medical practices
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 Pain
• How is the mechanism and
how to assess………?

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 Definition of pain
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described
in terms of such damage” IASP

• In reality,
it’s what the patient says it is.
Lanny Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.
 Mechanism Based

Psychogenic
Physiologic / (functional)3
nociceptive1
Pain due to abnormal
responsiveness or function
Pain arising from
of the nervous system
activation of nociceptors
without neurologic deficit
or peripheral abnormality

Inflammatory2 Neuropathic1

Pain caused by injury to Pain arising as a direct

body tissues consequence of a lesion or
(musculoskeletal, disease affecting the
cutaneous or visceral) somatosensory system

1. Loeser JD, Treede RD. The Kyoto Protocol of IASP Basic Pain Terminology. Pain 2008;137:473-477.
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57.
3. Woolf CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management. Ann Intern Med 2004;140:441-
451
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 Case # 1
• Mr B 23/M
• Acute pain
• On his right ankle
• History of falling during
play basketball 2 hour ago

• Why pain?

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 Pain Physiology

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 Mechanism of pain

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 Release and creation of pain mediators
Tissue damage

Release Formation

Transmitters Ions Kinins Prostaglandins

ACH K+ Bradykinins Prostaglandin E2

Histamines H+

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Striebel, W.: Treatment of Chronic Pain Schattauer, 2002
17 13
 Injury-induced Pain:
Patient Factors
Injury

Individual
variation in Individual
response to injury: variation in
physiological, response to
behavioral, treatment
and cultural

Complaint of pain

McQuay H. BMJ 1997;314:1531.

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 How to assess the pain ?

The most reliable

indicator of the
existence pain and its
intensity is the
patient’s description.

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 Case # 2
• Ms. D 35/F
• Pain on both hands
• Since 2 months
• Swollen
• Has GI problem (gastritis)

• How is the pain?,

• What is the diagnosis?

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 Assessment of pain
Goals:

• Achieve diagnosis of pain and underlying disorder

• Characterizing and quantifying the pain

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 Achieve diagnosis and
underlying disorder

History taking

Pattern : onset, duration, frequency

Area : location, topography
Intensity: level
Nature : description, history of
similar episodes,
intervention & what helped

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 Question to evaluate pain
P-Q-R-S-T format
Provocation How the injury occurred & what activities  
the pain, exacerbating and alleviating factors
Quality characteristics of pain (tingling, burning, dull)
Referral/ Referred – site distant to damaged tissue that
Radiation does not follow the course of a peripheral
nerve.
Radiating – follows peripheral nerve; diffuse

Severity How bad is it? Pain scale

Timing When does it occur? p.m., a.m., before,
during, after activity, all the time

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 Pain was assessed using
Visual Analogue Scale (VAS)

Adapted from : G. B. Langley1 and H. Sheppeard1(1) 

Medical Research Laboratory, Public Hospital, Palmerston North, New Zealand. Received: 21 May 1984  Accepted:
20 September 1984  
.

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Q
 Pain assessment tools

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 PAIN INTENSITY
75% of patients suffer moderate-severe pain
Median Pain Score: 5
100%

17% 25%
80%

18%
60% 7-10 (Severe)
58%
4-6 (Moderate)
14%
12%12%
40% 0-3 (Mild)

8% 7%
20%
26% 2% 2%
0% 1%
0%
All Pain Patients
0 1 2 3 4 5 6 7 8 9 10

7994 patients who suffered pain

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 Physical examination
• General PE: Vital sign

• Regional examination

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 Musculoskeletal examination
• Inspection: look for redness,
swelling, deformity
• Palpation : Test for warmness
Test for deep/ superficial
muscle tenderness
• Range of motion

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 Neurological examination
• Mental status
• Cranial nerves
• Motor function: weakness, ataxia
• Sensory function
• Reflexes

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 Evaluate the functional status

– How does it affect physical function

and work (ADLs)?
– How does it affect social and mental
functioning?

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 Evaluate the pain
• Identify comorbid conditions
• Identify past medical history
• Family history

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 Additional examination
• Imaging
• Laboratory
• Psychosocial

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How to make diagnosis?

Musculoskeletal Pain

Anamnesis & PE
Non-articular Articular
Acute Chronic
Tendonitis
Bursitis Inflammation
Yes No/ Minimal
OA
Monoarthritis Poliarthritis
Gout
Spine Involvement
Septic Arthritis
Trauma Prominent Minimal/None
AS, PsA* RA, Viral*,
SLE* ReA*
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 Goals in Pain Management
• Involve the patient in the decision-making process
• Agree on realistic treatment goals before starting a
treatment plan

Optimized pain
relief Minimized
Improved function adverse effects

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Farrar JT et al. Pain 2001; 94(2):149-58; Gilron I et al. CMAJ 2006; 175(3):265-75.
 Identify Pain Treatment Options

• Non-Drug Therapies

• Drug Therapies

• More Invasive Therapies

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 Treatment of PAIN

RATIONALE NSAIDS

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 Inflammation

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 Mechanism-Based Treatment of
Inflammatory Pain

Pain Treatment Options Brain

• Acetaminophen
• nsNSAIDs/coxibs
• Opioids
Damaged joint tissue
• Local anesthetics/
channel blockers
• Intra-articular corticosteroid/
Inflammatory
chemical hyaluronate injections
mediators Changed
responsiveness
of neurons in CNS
Changed responsiveness (central sensitization)
of nociceptors
(peripheral
sensitization)
Nociceptive afferent fiber
Spinal cord

CNS = central nervous system; coxib = COX-2 inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug
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Hochberg MC et al. Arthritis Care Res (Hoboken) 2012; 64(4):465-74; Scholz J et al. Nat Neurosci 2002; 5(Suppl):1062-7.
 Drug therapy

Strength

Durability

Safety Tolerability

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 What are NSAIDs (nsNSAIDs/coxibs)?

NSAID = Non-Steroidal Anti-Inflammatory Drug

• Analgesic effect via inhibition of prostaglandin
production
• Broad class incorporating many different
medications:
Examples of nsNSAIDs: Examples of Coxibs:
– Mefenamic Acid – Celecoxib
– Piroxicam – Etoricoxib
– Diclofenac – Parecoxib

coxib = COX-2-specific inhibitor; nsNSAID = non-specific non-steroidal anti-inflammatory drug

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Brune K. In: Kopf A et al (eds). Guide to Pain Management in Low-Resource Settings. International Association for the Study of Pain; Seattle, WA: 2010.
 How do nsNSAIDs/coxibs work?
Arachidonic acid

COX-2 (induced by
COX-1 (constitutive)
inflammatory stimuli)

Coxibs BLOCK

BLOCK nsNSAIDs BLOCK

Prostaglandins Prostaglandins

Gastrointestinal
cytoprotection, Inflammation, pain, fever
platelet activity
Coxib = COX-2-specific inhibitor; NSAID = non-steroidal anti-
inflammatory drug
nsNSAID = non-specific non-steroidal anti-inflammatory drug Pain relief
Gastrosource. Non-steroidal Anti-inflammatory Drug (NSAID)-Associated Upper
Gastrointestinal Side-Effects. Available at: http://www.gastrosource.com/11674565?
itemId=11674565.
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Accessed: December 4, 2010; Vane JR, Botting RM. Inflamm Res 1995;44(1):1-10.
 AHA Scientific Statement 2006: Impact of
COX-2 Selectivity of NSAIDS on CV and GI Risk

AHA: American Heart Association VIGOR: Rofecoxib 50 mg/day

Antman et al. Circulation 2007; 115: 1634- EDGE: Etoricoxib 90 mg/day
1642 Grosser et al. J. Clin. Invest. 2006;116:4–
Lanny CLASS: Celecoxib 200 mg BID
 COX-2-Selective and Non-Selective NSAIDs:
COX-1 Inhibiting Activity
Proportional inhibition of COX-1 when COX-2 is inhibited by 80%
100

80
% of COX-1 activity

60

40

20

Please refer to Product Information (labelling) in your country as not all products are approved for use being discussed
Data from an in-vitro blood-based assay to show the varying inhibitions of COX-1 coupled to concentrations of drugs that inhibit COX-2 by 80%.
Warner et al. Lancet 2008; 371: 270–73. Data from Warner et al. Proc Natl Acad Sci USA 1999; 96: 7563–68.
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 PRECISION

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Lanny
 Case # 1
• Mr B 23/M
• Acute pain 2 hours ago
• On his right ankle
• History of falling during
play basketball 2 hour ago

• What is the diagnosis?

• PE: Warmth, swelling, pain

Pattern : onset, duration, frequency limited range of motion
Area : location, topography
Intensity: level
Nature : description, history of
Trauma and ankle sprain
similar episodes,
intervention & what helped

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 Case # 2
• Ms. D 35/F
• Pain on both hands
• Since 2 months
• Swollen, tender. (>10 joitns)
Warm, morning stiffness
• Has GI problem (gastritis)
• Lab: RF (+), ↑ESR
• What is the diagnosis?

Pattern : onset, duration, frequency

Area : location, topography
Intensity: level
Nature : description, history of
Rheumatoid arthritis similar episodes,
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 Summary
• Pain is the most complain patients look
for help
• Understand the mechanism of pain is
important to make the right diagnosis
• Assess the pain help the physician to
give the appropriate treatment
• Treatment based on the type of pain and
the disease cause the pain
• Secure the safety of using any medicines

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