Ai Balanced multimodal analgesia

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Balanced (multimodal) analgesia uses two or more analgesic agents that act by different mechanisms to achieve a superior analgesic effect without increasing adverse events compared with increased doses of single agents. For example, epidural opioids can be administered in combination with epidural local anaesthetics; intravenous opioids can be administered in combination with NSAIDs, which have a dose sparing effect for systemically administered opioids.

Balanced analgesia is therefore the method of choice wherever possible, based on paracetamol and NSAIDs for low intensity pain with opioid analgesics and/or local analgesia techniques being used for moderate and high intensity pain as indicated (Figure 4, page 18).

The example doses given are indicative and do not take account of individual patient variation.

Table 2

Pharmacological options of pain management

Non-oplold analgesics


NSAIDs, Including COX-2 Inhibitors* Gabapentin, pregabalin2

Paracetamol combined with codeine or tramadol






Ketamlne Clonidine

* At the time of writing, COX-2 inhibitor drugs are subject to scrutiny by international regulatory bodies with regard to adverse outcomes when used for long-term oral prescription or for pain relief in patients with cardiovascular problems such as myocardial infarction, angina pectoris, hypertension. Rofecoxib has been withdrawn from sales and prescription of valdecoxib has been suspended pending further research into its adverse events profile for cardiovascular morbidity and the occurrence of severe muco-cutaneous side effects. The injectable COX-2 inhibitor, parecoxib remains available for short-term use in treating postoperative pain. All NSAIDs should be used with care in patients with cardiovascular disease.

** These adjuvants are not recommended for routine use in acute pain management because of their adverse side effects. Their use should be restricted to specialists in managing pain problems.

2 Gabapentin and pregabalin are approved for pain management but at the time of writing there is little published data to recommend the use of these drugs for acute pain management.

Figure 4

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