Inguinal hernia is a common disease in general surgery, and surgery is its main treatment method. Chronic pain after inguinal hernia (CPIP) as one of the indicators of surgical efficacy refers to moderate or severe pain after inguinal hernia, affecting daily life and lasting for more than 3 months. It mainly includes neuropathic pain (can occur during or after surgery), non-neuropathic pain (nociceptive pain), somatic pain and visceral pain [1].
There is currently no special drug for treating CPIP. The most commonly used analgesic drugs are weak opioids and non-steroidal anti-inflammatory drugs (NSAIDs) [1]. "The Diagnosis and Treatment Progress of Chronic Pain After Inguinal Hernia" (2021) pointed out that γ-aminobutyric acid analogs (such as gabapentin , pregabalin ), 5-hydroxytryptamine and norepinephrine reuptake dual inhibitors (SNRIs) and tricyclic antidepressants (TCAs) should be used as first-line treatment drugs for CPIP. If the treatment is poor, it is recommended to use second-line treatment drugs such as opioids and tramadol [1].
1. Nonsteroidal anti-inflammatory drugs (NSAIDs)
includes non-selective NSAIDs (such as ibuprofen , diclofenac , indomethacin, flubiprofen esters,) and selective COX-2 inhibitors (such as celecoxib, erecoxib), which can be anti-inflammatory and analgesic, and have a certain effect on pain caused by nerve impairment in inflammatory nociceptive pain. It can be used for the treatment of CPIP [1-2]. Among them, non-selective NSAIDs flubiprofen ester and selective COX-2 inhibitors celecoxib and parecoxib can pass through the blood-brain barrier and effectively inhibit peripheral and central pain sensitization. It is suitable for preventive analgesia. Preoperative administration can prevent postoperative pain and reduce postoperative pain and central sensitization caused by nociceptive stimulation [3-5].
Notes: It can cause gastrointestinal reactions, liver damage, hematuria , renal necrosis, peripheral blood cell loss, bleeding, cardiovascular events and other side reactions [2,7-8]. It is contraindicated for myocardial infarction and recently undergoing coronary artery bypass graft [2,7-8].
2. Calcium channel blocker
, such as gabapentin and pregabalin, are γ-aminobutyric acid analogs, which can analgesic, inhibit hyperalgesia and central sensitization, and can also resist neuropathological pain. Oral preoperative treatment can relieve postoperative pain and can be used as a first-line treatment drug for CPIP [1,9-11]. In addition, oral pregabalin night before the surgery can improve sleep and relieve anxiety [5].
Notes: It can cause side reactions such as drowsiness, dizziness, headache, peripheral edema, etc. [12].
III. Antidepressant drugs
5-hydroxytryptamine and norepinephrine re-uptake dual inhibitors (SNRIs) such as dexoloxetine , venlafaxine , and tricyclic antidepressant drugs (TCAs) such as amitriptyline , can analgesic, antidepressant anxiety, improve mood and sleep, and can also resist neuropathic pain. It can be used as the first-line treatment drug for CPIP [1,12-14].
Note: SNRIs can cause side reactions such as dry mouth, constipation, sedation, tremor, , dysuria, dysuria, , etc. (instructions). TCAs can cause side effects such as dry mouth, dysuria, cardiotoxicity, etc., and avoid being used in [12] for those at risk of ischemic heart disease or sudden cardiac death.
4. Opioid
includes weak opioids such as codeine, dihydrocodeine, etc., and strong opioids such as morphine, mediidine, fentanyl, oxycodone, sufentanyl, hydromorphone, etc., which can be used for the treatment of moderate to severe pain and can be used as the second-line treatment drug for CPIP [1,15-18].
Precautions: It can cause constipation, nausea and vomiting, dizziness, urinary retention, respiratory depression, drug dependence, etc. [19-20].
5. Tramadol
Tramadol is a centrally powerful analgesic drug that can analgesic, antidepressant and anxiety. It is a weak μ opioid receptor agonist and inhibits serotonin and norepinephrine reuptake. It can be used for mild to moderate pain, has little impact on gastrointestinal function, and is weaker in efficacy than strong opioids, but it is better tolerated than strong opioids. It can be used as a second-line treatment drug for CPIP [1,13,16].
Precautions: It can cause nausea and vomiting, palpitations, , drowsiness, dizziness, dyspnea, epilepsy seizures, , etc. [21]. It is contraindicated for patients with known or suspected gastrointestinal obstruction, acute or severe asthma (no resuscitation equipment or no monitoring), and severe respiratory depression [21].
6. glucocorticoid
can anti-inflammatory and analgesic, and it has a certain effect on pain caused by nerve impairment in inflammatory nociceptive pain [1,22]. However, its adverse reactions in long-term treatment of chronic pain are relatively large, which restricts the use of [1].
References:
1. Sun Binjie et al. Diagnosis and treatment progress of chronic pain after inguinal hernia [J]. International Journal of Surgery, 2021, 48(7): 493-497.
2. Expert consensus on the clinical application of perioperative non-steroidal anti-inflammatory drugs in the accelerated rehabilitation of surgery in China [J]. Chinese Journal of General Surgery, 2019, 34(3): 283-286.
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4. Chinese Expert Consensus for the Management of Chronic Musculoskeletal Pain in Elderly Patients (2019)[J]. Chinese Journal of Geriatric Medicine, 2019, 38(5): 500-504.
5. Expert Consensus for Perioperative Application of Non-Opioid Analgesics in Adults [J]. International Journal of Anesthesiology and Resuscitation, 2019, 40(1): 1-6.
6. Expert consensus on clinical drug treatment of osteoarthritis [J]. Chinese Journal of Frontier Medicine, 2021, 13(7):32-40.
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8. Expert consensus on pain management in adults after surgery [J]. Journal of Clinical Anesthesiology, 2017, 33(9):911-917.
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11. Guidelines for postoperative pain management of clinical pharmacists (Guangdong Pharmaceutical Society January 31, 2019).
12. Chinese Expert Consensus on Diagnosis and Treatment of Neurological Pain in Postherpes Zoth[J]. Chinese Journal of Pain Medicine, 2016, 22(3):163-164.
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15. Beijing Cancer Pain Management Standards (2017 Edition) [J]. Chinese Journal of Pain Medicine, 2017, 23(12): 881-889.
16. Shanghai Expert Consensus for Cancer Pain Diagnosis and Treatment (2017 Edition) [J]. Chinese Journal of Cancer, 2017, 27(4): 312-317.
17. Expert Consensus for Cancer Pain Management [J]. Chinese Journal of Pain Medicine, 2019, 25(11): 801- 806.
18. Anhui Province Cancer Pain Diagnosis and Treatment Expert Consensus (2019 Edition) [J]. Anhui Medicine, 2020, 24(5):1041-1046.
19. Expert Consensus on Adverse Reactions of Analgesic Drugs [J]. Electronic Journal of Tumor Metabolism and Nutrition, 2021, 8(2):139-141.
20. Expert Consensus on Adverse Reactions of Opioid Drugs [J]. Chinese Tumor Clinic, 2019, 46 (7):321-323.
21. Announcement of the State Administration of Drug Administration on Revising the Instructions for Tramadol Injection and Uniprepared Oral Dosage (No. 28, 2021).
22. Guiding Principles for Clinical Application of Glucocorticoid Drugs [J]. Chinese Journal of Endocrine and Metabolism, 2012, 28: Added 2a-1-32.
Written by: Gao Lili
Reviewed: LR
Execution: LR
