Adjuvants or Co-analgesics

Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is
the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these
materials, or for any errors or omissions.
Objectives

• Review different forms of adjuvant or co-analgesic medication

• Understand adult dosing for each
• Learn when to utilize them
• Review potential side effects

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Adjuvant analgesics or co-analgesics

Adjuvant analgesics, which are also referred to as co-analgesics,

are medicines that are not primarily used for analgesia. These
are medicines that are administered alone or with NSAIDs and
opioids that may:
• Enhance the analgesic activity of the NSAIDs or opioids
• Have independent analgesic activity for certain pain types
(such as neuropathic pain)
• May counteract the side effects of NSAIDs or opioids

Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010) 3
Principles in adjuvant therapy

• The use of adjuvants that target neuropathic pain may be

particularly important because such pain may be difficult to
treat with opioids alone
• Adjuvants are also useful for other pains that are only partially
sensitive to opioids such as bone pain, smooth or skeletal
muscle spasms, or pain related to anxiety

Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010) 4
Antidepressants

Used for neuropathic pain, presenting primarily as burning or

abnormal sensations (dysaesthesia)
• Amitriptyline
– Adults: 10-75mg or 0.5-2mg/kg at night then increase
slowly as needed
– Commonly start at 12.5mg at night and then increase to
twice per day as needed
– Response should be evident within 5 days
• If no effect after 1 week, stop the drug

Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010); Introductory Palliative Care Course for Health Care5
Professionals (Uganda). PCAU/MOH (2013).
Antidepressants

– Side-effects include dry mouth and drowsiness

– Use with caution in the elderly because it may increase
falls
– Use with caution in those with cardiac disease because it
may cause orthostatic hypertension
• Nortriptyline
– May be better tolerated than amitriptyline

Beating Pain, 2nd Ed. APCA (2012); Using Opioids to Manage Pain, APCA (2010); Introductory Palliative Care Course for Health Care6
Professionals (Uganda). PCAU/MOH (2013).
Anticonvulsants

Use for neuropathic pain; check for drug interactions

• Clonazepam
– Adults: 0.5mg to 2mg once a day
• Carbamazepine
– Adults: start at 100mg twice a day and can be increased up to 800mg twice a day
• Sodium valproate
– Adults: 200 mg - 1.2g once a day
• Gabapentin
– Adults: start with 300mg at bedtime and titrate up every 2 or 3 days (300mg twice
per day, then three times per day) until effective or side effects occur
– Usual effective dose is 300-600mg three times a day (maximum dose 1200mg
three times per day)
– Decrease dose in patients with renal insufficiency

Beating Pain, 2nd Ed. APCA (2012); Palliative Care for HIV/AIDS and Cancer Patients in Vietnam, Basic Training Curriculum: Harvard
Medical School, Centre for Palliative Care (2007); Oxford Textbook of Palliative Medicine (2010) 7
Anticonvulsants

• Use Phenytoin and Carbamazepine with caution because of

the rapid metabolism of other drugs metabolized in the liver
and therefore potential drug interactions
• Side effects: drowsiness, loss of muscle coordination (ataxia)
or blurring of vision

Beating Pain, 2nd Ed. APCA (2012) 8

Antispasmodics

Use antispasmodics for muscle spasm, e.g. colicky abdominal

pain or renal colic
• Hyoscine butylbromide (Buscopan)
– Adults: start at 10mg three times a day; can be increased
to 40mg three times a day
• Antispasmodics can cause nausea, dry mouth, or constipation

Beating Pain, 2nd Ed. APCA (2012) 9

Muscle relaxants

Use these drugs for skeletal muscle spasm and anxiety-related

pain
• Diazepam
– Adults: 5mg orally 2 or 3 times a day
• Lorazepam
– 0.5-2mg oral or intravenous every 3 to 6 hours
• Side effects: can cause drowsiness and ataxia

Beating Pain, 2nd Ed. APCA (2012); Oxford Textbook of Palliative Medicine. (2010) 10
Corticosteroids

Use corticosteroids for bone pain, neuropathic pain, headache due to raised
intracranial pressure, and pain associated with oedema and inflammation
• Dexamethasone
– Adults: 2–4mg per day for most situations
– For raised intracranial pressure, start at 24mg per day and reduce by 2mg each day to
the lowest effective maintenance dose
– For pain from nerve compression, start at 8mg
– For spinal cord compression, start at 16mg

• Prednisolone
– Use when dexamethasone is not available
– A conversion rate of 4mg Dexamethasone(*7.5) to 30mg Prednisolone can be used

Beating Pain, 2nd Ed. APCA (2012) 11

Corticosteroids

• In advanced disease, a corticosteroid may improve

appetite, decrease nausea and malaise, and improve
quality of life
• Side effects include neuropsychiatric syndromes,
gastrointestinal disturbances and immunosuppression
• When stopping a corticosteroid, remember gradually
taper down the dose

Beating Pain, 2nd Ed. APCA (2012) 12

Bisphosphonates

Bisphosphonates are used for the treatment of cancer-related

bone pain
• Pamidronate- 60-90mg slow intravenous infusion every 4
weeks
• Side effects
– Fever and flu-like weakness
– Osteonecrosis of the jaw, although rare, has been
associated with bisphosphonate therapy

Beating Pain, 2nd Ed. APCA (2012) 13

Take home messages

• Co-analgesics are important complementary medications in

pain relief
• Used with the correct combinations, co-analgesics can
enhance analgesic effects
• Adjuvants are useful for neuropathic pain and other pains that
are only partially sensitive to opioids such as bone pain,
smooth or skeletal muscle spasms, or pain related to anxiety

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References

• African Palliative Care Association. Beating Pain: a pocketguide for pain management
in Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf
• African Palliative Care Association. Using opioids to manage pain: a pocket guide for
health professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf
• Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-
Africa-Full-Text.pdf
• Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings
[Internet]. 2010. Available from:
http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/FreeBooks/
Guide_to_Pain_Management_in_Low-Resource_Settings.pdf
• The Palliative Care Association of Uganda and the Uganda Ministry of Health.
Introductory Palliative Care Course for Healthcare Professionals. 2013.
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