Chinese Prescription Drugs, August 2008, Vol. 77, No. P68-69 Inflammation and pain in the joints are the most common manifestations of rheumatologic diseases, so analgesia and anti-inflammation are among the most important elements of rheumatologic therapeutics. However, analgesia and anti-inflammation only control symptoms and manage rheumatic diseases, which require the use of disease relieving anti-rheumatic drugs (DMARDs). The subject of this article is only about analgesia and anti-inflammation. : I. Clinical experience of NSAID drip Although clinically, most patients have good efficacy and tolerability of various NSAIDs, individualized medication according to patient’s specific situation and characteristics of the drug will obtain lower cost, better efficacy, and less side effects. The following discussion is based on the author’s experience on the individualized use of NSAIDs. In fact, more than half of arthritis patients have good tolerance and efficacy for any of the NSAIDs. Meloxicam and diclofenac sodium have strong anti-inflammatory and analgesic effects and good tolerability; indomethacin and piroxicam have strong anti-inflammatory and analgesic effects but are poorly tolerated in the gastrointestinal tract. Naproxen and ibuprofen have milder effects and are better tolerated in the gastrointestinal tract. Therefore, for young and strong patients without gastrointestinal disorders, it is recommended to use affordable traditional NSAIDs. 2. The gastrointestinal safety of celebrex drugs is better The gastrointestinal safety of celebrex drugs is better, and the price is more expensive. However, if you choose a traditional NSAID and a gastric proton pump inhibitor in combination, it is better to choose a celebrex drug. For those with a history of gastrointestinal disorders and gastrointestinal bleeding who have to use NSAIDs, cribrials are also a better choice. The recently marketed celebrex is the first NSAID with gouty arthritis as an indication. The pain level of gouty arthritis can be considered the most painful in rheumatology, therefore, celebrex is called “the NSAID that dares to challenge gout analgesia”. If hormones and NSAID are used together, the powerful anti-inflammatory effect of hormones can almost cover up the anti-inflammatory effect of NSAID, so that the effect of NSAID to inhibit cyclooxygenase is only reflected in the side effects. The combination of low-dose hormones and NSAID is: a low-dose hormone (prednisone ≤ 10 mg/d) orally at 8 AM and a longer-acting NSAID orally at night, because low-dose hormones have very good anti-inflammatory effects and gastrointestinal tolerance, and for more severe arthritis, it is better to blindly increase the dose of NSAID than to use it in combination with low-dose hormones. Following the physiological curve of human adrenocorticotropic hormones, oral administration of low-dose hormones at 8AM rarely results in significant side effects as long as the course of treatment is not too long. However, hormones should not be taken at night because oral hormones at night, even in very small doses, can seriously interfere with the physiological secretion of one’s own hormones. Proper use of hormones and NSAIDs together can maximize anti-inflammatory and analgesic efficacy and reduce side effects. Nimesulide is a special NSAID because it has a very strong anti-inflammatory and antipyretic effect, and there is hardly any NSAID that can compete with it in this regard, but it does not have an advantage in the analgesic effect of arthritis. not rheumatologists or orthopedics. In the mid to late 1990s, the market for nimesulide began to shift to the treatment of arthritis. Because of the large number of patients with arthritis and the long duration of dosing, the potential hepatotoxicity of nimesulide rapidly manifested itself and attracted attention as the prescription of nimesulide rapidly increased. Since the analgesic effect of nimesulide on arthritis is not strong, and the hepatotoxicity is more obvious than other NSAIDs, we do not advocate the use of nimesulide for arthritis. However, it has special efficacy in some non-infectious, non-neoplastic fevers and/or inflammatory conditions, such as adult Still’s disease, reactive lymphadenitis, and Wegener’s granulomatosis, etc. Nimesulide is often effective in fevers of some autoimmune diseases, when even high doses of hormones fail to reduce the fever. Rheumatologists who master the clinical characteristics of Nimesulide will add a very effective weapon. Another point that needs to be accounted for is that the current drug instructions state that the dose of nimesulide is 100mg to 200mg twice daily. Our experience is that for anti-inflammatory and antipyretic purposes most patients need only a very small dose, 50 mg of nimesulide twice daily, which is mostly sufficient, with only a few patients requiring an increase to 100 mg twice daily. In recent years, we have adopted small doses of nimesulide, and there are very few problems of nimesulide hepatotoxicity. In recent years, we have seen two copies of the top 10 drugs prescribed by rheumatologists in the United States from Rheumatology News, a newspaper for American specialists (Figure 1: Top 10 drugs prescribed by rheumatologists in 2006, from: Rheumatology News, 2nd edition, September 2007; Figure 2: Rheumatologists, January-March 2008). (Top 10 drugs prescribed by rheumatologists, from: Rheumatology News, 1st edition, June 2008), which is felt to be informative. The neuroleptic tramadol and neuroleptic + acetaminophen are commonly used by rheumatologists in the US. Reflecting on the prescribing habits of our Chinese rheumatologists, these types of analgesics are used very rarely. Is it because American rheumatologists abuse analgesics or our analgesics are used too conservatively? 1, non-inflammatory pain to analgesics mainly if given to patients with non-inflammatory pain NSAIDs, NSAIDs anti-inflammatory effect is purely redundant, and NSAIDs gastrointestinal side effects, renal safety and cardiovascular safety issues, and anti-inflammatory for the same point of use, are due to the inhibition of cyclooxygenase. Therefore, for non-inflammatory pain, such as fibromyalgia, osteoarthritis without synovitis, pain caused by intervertebral disc or osteophyte compression of nerves, etc., then analgesics should be used instead of NSAIDs. 2, alternative drugs for inflammatory pain When there are contraindications to the use of NSAIDs in patients with inflammatory pain, neuroleptic analgesics need to be used to control symptoms and reduce pain. Contraindications to the use of NSAIDs include: active peptic ulcers, or gastrointestinal bleeding; renal insufficiency, or renal hypoperfusion (low sodium, hypotension, cirrhosis, nephrotic syndrome, congestive heart failure, etc.) requiring physiological regulation by prostaglandins, etc. In inflammatory pain, if the “small dose of hormones and NSAIDs” mentioned earlier still cannot achieve satisfactory analgesic effect, it is better to increase the dose of hormones or NSAIDs than to add analgesics to avoid side effects caused by blindly increasing the dose of hormones or NSAIDs. 3. The usage of analgesics in rheumatology There are more types of analgesics, which are mainly used in anesthesiology and pain medicine. As seen in Figure 1 and Figure 2, the main analgesics used in rheumatology are tramadol and compound acetaminophen. The most common side effects of tramadol use by rheumatologists are dizziness and nausea and vomiting, which occur mainly at the beginning of the drug administration, so tramadol use should be started at small doses. Our experience is to start with tramadol 50mg (half a tablet) once a night and gradually increase the dose after 1 week if the analgesic effect is not satisfactory. Individuals who also experience dizziness and nausea and vomiting with Tramadol 50mg can start with 25mg (1/4 tablet) or 33.3mg (1/3 tablet). Andonan is compounded acetaminophen with the ingredients acetaminophen + tramadol. Dosage is: start with 1 tablet per night and gradually increase the dose as needed.