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The valid messages and recommendations from the S3 guideline on chronic pancreatitis require some additions, and some verification, in the section entitled “The treatment of pain.”

Before initiating symptomatic medication or endoscopic or surgical pain treatment, a detailed analysis of the pain should be conducted in order to identify possible non-visceral (partial) causes of chronic upper abdominal pain, such as psychological disorders or musculoskeletal pain syndromes (1). In a proportion of patients with chronic pancreatitis, central pain is present that responds unsatisfactorily to surgical or endoscopic procedures (1).

The intensity of pain in chronic alcohol toxic pancreatitis correlates with the presence of affective disorders and further chronic pain syndromes but not with the CT results of chronic pancreatitis. Within a stepwise pain management approach, the first step should be to wean patients with chronic pancreatitis and substance dependency (alcohol, tobacco) off the substance they are misusing (2). The problem of misuse of prescribed opioids in substance-dependent persons deserves mentioning.

In a three-week randomized controlled study, pregabalin was superior to placebo regarding effective pain reduction (36% versus 24%) (3). Pregabalin was not listed among the options for drug therapy in the article.

Regarding Table 4 of the article: because of the half-lives of paracetamol (acetaminophen) and metamizole, the recommendation is for a minimum of 4 doses per day in patients with chronic pain. Levopromazine is a neuroleptic of low potency, not a tricyclic antidepressant. The use of neuroleptics in the treatment of chronic pain should be regarded critically because of limited data and because of the drugs’ side effects.

DOI: 10.3238/arztebl.2013.0686a

PD Dr. med. Winfried Häuser

Innere Medizin 1

Klinikum Saarbrücken

whaeuser@klinikum-saarbruecken.de

Conflict of interest statement

PD Dr Häuser is the speaker of the working group on visceral pain (Arbeitskreis Viszerale Schmerzen) in the German Pain Society reg assoc.

He has received lecture honoraria from Abbott and Pfizer as well as a consulting fee from Daiichi Sankyo.

1.
Conwell DL, Vargo JJ, Zuccaro G, et al.: Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis. Am J Gastroenterol 2001; 96: 431–6 CrossRef MEDLINE
2.
Chauhan S, Forsmark CE: Pain management in chronic pancreatitis: A treatment algorithm. Best Pract Res Clin Gastroenterol 2010; 24: 323–35 CrossRef MEDLINE
3.
Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM: Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial. Gastroenterology 2011; 141: 536–43 CrossRef MEDLINE
4.
Mayerle J, Hoffmeister A, Witt H, Lerch MM, Mössner J: Chronic pancreatitis—definition, etiology, investigation and treatment. Dtsch Arztebl Int 2013; 110(22): 387–93 VOLLTEXT
1.Conwell DL, Vargo JJ, Zuccaro G, et al.: Role of differential neuroaxial blockade in the evaluation and management of pain in chronic pancreatitis. Am J Gastroenterol 2001; 96: 431–6 CrossRef MEDLINE
2.Chauhan S, Forsmark CE: Pain management in chronic pancreatitis: A treatment algorithm. Best Pract Res Clin Gastroenterol 2010; 24: 323–35 CrossRef MEDLINE
3.Olesen SS, Bouwense SA, Wilder-Smith OH, van Goor H, Drewes AM: Pregabalin reduces pain in patients with chronic pancreatitis in a randomized, controlled trial. Gastroenterology 2011; 141: 536–43 CrossRef MEDLINE
4.Mayerle J, Hoffmeister A, Witt H, Lerch MM, Mössner J: Chronic pancreatitis—definition, etiology, investigation and treatment. Dtsch Arztebl Int 2013; 110(22): 387–93 VOLLTEXT

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