Der Schmerz
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In a double-blind, randomized, placebo-controlled study, 112 patients scheduled for knee-joint arthrotomies or minor orthopaedic operations received 75 mg diclofenac, 600 mg apazone, the combination of 75 mg diclofenac and 600 mg apazone, or placebo (50 ml NaCl 0.9%) as a single i.v. dose immediately after operation. Postoperative pain intensity was measured by a numeric rating scale. All patients were allowed to self-administer piritramide from a PCA (patient-controlled analgesia) pump (Prominjekt, Pharmacia, Sweden) in 2-mg boluses every 5 min during the first 6 h and subsequently every 15 minfor another 18 h after surgery. ⋯ The incidence of typical side effects of opioids and antipyretic anti-inflammatory analgesics (nausea, vomiting, stomach ache, headache, vertigo) was low, and they were easily controlled in all cases. Postoperative combined application of the nonsteroidal anti-inflammatory analgesics diclofenac and apazone results in a significantly lower opioid requirement (about 60%) after minor orthopaedic surgery. The opioid-sparing effect appears to be superior to that of diclofenac (44%) or apazone (42%) alone, but this was not statistically significant.
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In 1986 the World Health Organisation (WHO) proposed an analgesic ladder for the effective therapy of cancer pain. The three standard analgesics making up this ladder are aspirin (non-opioid), codeine (weak opioid) and morphine (strong opioid). Adjuvant drugs may be added at any level. However, before 1986 step II analgesics (weak opioids) had never been tested in cancer pain relief. ⋯ The use of the WHO guidelines "by mouth, by the clock and by the ladder" is now the mainstay of cancer pain management. Because of the guidelines' simplicity they found general acceptance and helped to establish an international pain therapy standard for worldwide use. Nevertheless, there is no scientific validation of WHO step II. In the absence of prospective controlled randomized trials additional longterm results are necessary. We need more data on the use of WHO step II and an update of the published guidelines taking account of modern sustained-release drugs. Up to now, step II of the WHO guidelines for cancer pain is not a clinical reality but at best a didactic instrument.
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Analgesic pharmacotherapy represents one of the major approaches to the treatment of cancer pain, since it is used in almost every patient. A thorough evaluation of the physical and mental status of the patient and of the pain is as necessary as a sound understanding of the pharmacokinetic and pharmacodynamic characteristics of the analgesics selected. The World Health Organization (WHO) has issued a basic 3 stage progression for the treatment of cancer pain, the "WHO Analgesic Ladder". ⋯ The most common of these is constipation; nausea, vomiting and sedation occur mostly at the start and can usually be treated effectively. The appropriate dosage, route of administration and dosage scheme of analgesics needs to be worked out for each individual patient in intensive work with the patient and a close follow-up, for years if necessary. Some analgesics may not be available in some countries, or only in specific preparations.