Stepped care drug management of sacroiliac joint pain
| Drug | Dose/titration * | Important adverse effects/precautions |
|---|---|---|
| Topical preparations | Lidocaine 5% bid-tid; diclofenac gel 1% bid. | Efficacy evidence is limited. |
| Acetaminophen | 325–1000 mg q4–6h, max 3 gm/d. Adjust dosing interval for renal function: CRcl 10–50: q6 hrs; CrCl < 10: q8 hours. | Ask about all OTCs with acetaminophen; increased toxicity from chronic use if heavy EtOH use, malnourishment, pre-existing liver disease—decrease maximum daily dose to 2 gm. |
| Salsalate | Salsalate: 500–750 mg bid; maximum dose 3000 mg/day. | Does not interfere with platelet function; GI bleeding & nephrotoxicity rare; salicylate concentrations can be monitored if toxicity suspected. |
| Choline magnesium trisalicylate | Choline magnesium trisalicylate: 750 mg tid; maximum dose 3000 mg/day. | |
| Tramadol | Start 25 mg daily; increase by 25–50 mg daily in divided doses every 3–7 days as tolerated to max dose of 100mg QID. Renal dosing (CRcl < 30 ml/min) 100mg bid. | Seizures and orthostatic hypotension. Other side effects similar to traditional opioids including sedation, confusion, respiratory depression. Potential for serotonin syndrome if patient is on other serotonergics such as triptans, duloxetine, and other antidepressants. |
| Hydrocodone/acetaminophen | 2.5/325 or 5/325–10/650 mg q4–6h; max acetaminophen dose 3gm/d. Consider recommending a supplementary dose of APAP 325 or 500 mg with combination dose for additional analgesia before increasing the opioid dose. | For all opioids, increased risk of falls in patients with dysmobility. May worsen or precipitate urinary retention when BPH present. Increased risk of delirium in those with dementia. Because of increased sensitivity to opioids older adults at greater risk for sedation, nausea, vomiting, constipation, urinary retention, respiratory depression, and cognitive impairment. Start stimulant laxative at first sign of constipation. Some might start at initiation if patient has existing complaints of constipation or other risk factors. |
| Oxycodone or morphine | 5–10 mg oxycodone q4h (begin with 2.5–5mg q4h) OR morphine 2.5–5 mg q4h; assess total needs after 7d on stable dose, then convert to long acting. | Side effects as per hydrocodone.Start stimulant laxative at first sign of constipation.NEVER start long acting opioid before determining needs with short acting. |
| Duloxetine | Start 20–30 mg/d; increase to 60 mg/d in 7 d. Not recommended in ESRD or CLcr <30. | May precipitate serotonin syndrome when combined with triptans, tramadol, and other antidepressants. Key drug-disease interactions: HTN, uncontrolled narrow-angle glaucoma, seizure disorder. Precipitation of mania in patients with bipolar disorder. Important adverse effects include nausea, dry mouth, sedation/falls, urinary retention, constipation. Contraindicated with hepatic disease and heavy alcohol use. Abrupt discontinuation may result in withdrawal syndrome. Contraindicated within 14 days of MAOI use |
| Drug | Dose/titration * | Important adverse effects/precautions |
|---|---|---|
| Topical preparations | Lidocaine 5% bid-tid; diclofenac gel 1% bid. | Efficacy evidence is limited. |
| Acetaminophen | 325–1000 mg q4–6h, max 3 gm/d. Adjust dosing interval for renal function: CRcl 10–50: q6 hrs; CrCl < 10: q8 hours. | Ask about all OTCs with acetaminophen; increased toxicity from chronic use if heavy EtOH use, malnourishment, pre-existing liver disease—decrease maximum daily dose to 2 gm. |
| Salsalate | Salsalate: 500–750 mg bid; maximum dose 3000 mg/day. | Does not interfere with platelet function; GI bleeding & nephrotoxicity rare; salicylate concentrations can be monitored if toxicity suspected. |
| Choline magnesium trisalicylate | Choline magnesium trisalicylate: 750 mg tid; maximum dose 3000 mg/day. | |
| Tramadol | Start 25 mg daily; increase by 25–50 mg daily in divided doses every 3–7 days as tolerated to max dose of 100mg QID. Renal dosing (CRcl < 30 ml/min) 100mg bid. | Seizures and orthostatic hypotension. Other side effects similar to traditional opioids including sedation, confusion, respiratory depression. Potential for serotonin syndrome if patient is on other serotonergics such as triptans, duloxetine, and other antidepressants. |
| Hydrocodone/acetaminophen | 2.5/325 or 5/325–10/650 mg q4–6h; max acetaminophen dose 3gm/d. Consider recommending a supplementary dose of APAP 325 or 500 mg with combination dose for additional analgesia before increasing the opioid dose. | For all opioids, increased risk of falls in patients with dysmobility. May worsen or precipitate urinary retention when BPH present. Increased risk of delirium in those with dementia. Because of increased sensitivity to opioids older adults at greater risk for sedation, nausea, vomiting, constipation, urinary retention, respiratory depression, and cognitive impairment. Start stimulant laxative at first sign of constipation. Some might start at initiation if patient has existing complaints of constipation or other risk factors. |
| Oxycodone or morphine | 5–10 mg oxycodone q4h (begin with 2.5–5mg q4h) OR morphine 2.5–5 mg q4h; assess total needs after 7d on stable dose, then convert to long acting. | Side effects as per hydrocodone.Start stimulant laxative at first sign of constipation.NEVER start long acting opioid before determining needs with short acting. |
| Duloxetine | Start 20–30 mg/d; increase to 60 mg/d in 7 d. Not recommended in ESRD or CLcr <30. | May precipitate serotonin syndrome when combined with triptans, tramadol, and other antidepressants. Key drug-disease interactions: HTN, uncontrolled narrow-angle glaucoma, seizure disorder. Precipitation of mania in patients with bipolar disorder. Important adverse effects include nausea, dry mouth, sedation/falls, urinary retention, constipation. Contraindicated with hepatic disease and heavy alcohol use. Abrupt discontinuation may result in withdrawal syndrome. Contraindicated within 14 days of MAOI use |
*Abbreviations such as bid should be avoided in an effort to reduce errors.
Stepped care drug management of sacroiliac joint pain
| Drug | Dose/titration * | Important adverse effects/precautions |
|---|---|---|
| Topical preparations | Lidocaine 5% bid-tid; diclofenac gel 1% bid. | Efficacy evidence is limited. |
| Acetaminophen | 325–1000 mg q4–6h, max 3 gm/d. Adjust dosing interval for renal function: CRcl 10–50: q6 hrs; CrCl < 10: q8 hours. | Ask about all OTCs with acetaminophen; increased toxicity from chronic use if heavy EtOH use, malnourishment, pre-existing liver disease—decrease maximum daily dose to 2 gm. |
| Salsalate | Salsalate: 500–750 mg bid; maximum dose 3000 mg/day. | Does not interfere with platelet function; GI bleeding & nephrotoxicity rare; salicylate concentrations can be monitored if toxicity suspected. |
| Choline magnesium trisalicylate | Choline magnesium trisalicylate: 750 mg tid; maximum dose 3000 mg/day. | |
| Tramadol | Start 25 mg daily; increase by 25–50 mg daily in divided doses every 3–7 days as tolerated to max dose of 100mg QID. Renal dosing (CRcl < 30 ml/min) 100mg bid. | Seizures and orthostatic hypotension. Other side effects similar to traditional opioids including sedation, confusion, respiratory depression. Potential for serotonin syndrome if patient is on other serotonergics such as triptans, duloxetine, and other antidepressants. |
| Hydrocodone/acetaminophen | 2.5/325 or 5/325–10/650 mg q4–6h; max acetaminophen dose 3gm/d. Consider recommending a supplementary dose of APAP 325 or 500 mg with combination dose for additional analgesia before increasing the opioid dose. | For all opioids, increased risk of falls in patients with dysmobility. May worsen or precipitate urinary retention when BPH present. Increased risk of delirium in those with dementia. Because of increased sensitivity to opioids older adults at greater risk for sedation, nausea, vomiting, constipation, urinary retention, respiratory depression, and cognitive impairment. Start stimulant laxative at first sign of constipation. Some might start at initiation if patient has existing complaints of constipation or other risk factors. |
| Oxycodone or morphine | 5–10 mg oxycodone q4h (begin with 2.5–5mg q4h) OR morphine 2.5–5 mg q4h; assess total needs after 7d on stable dose, then convert to long acting. | Side effects as per hydrocodone.Start stimulant laxative at first sign of constipation.NEVER start long acting opioid before determining needs with short acting. |
| Duloxetine | Start 20–30 mg/d; increase to 60 mg/d in 7 d. Not recommended in ESRD or CLcr <30. | May precipitate serotonin syndrome when combined with triptans, tramadol, and other antidepressants. Key drug-disease interactions: HTN, uncontrolled narrow-angle glaucoma, seizure disorder. Precipitation of mania in patients with bipolar disorder. Important adverse effects include nausea, dry mouth, sedation/falls, urinary retention, constipation. Contraindicated with hepatic disease and heavy alcohol use. Abrupt discontinuation may result in withdrawal syndrome. Contraindicated within 14 days of MAOI use |
| Drug | Dose/titration * | Important adverse effects/precautions |
|---|---|---|
| Topical preparations | Lidocaine 5% bid-tid; diclofenac gel 1% bid. | Efficacy evidence is limited. |
| Acetaminophen | 325–1000 mg q4–6h, max 3 gm/d. Adjust dosing interval for renal function: CRcl 10–50: q6 hrs; CrCl < 10: q8 hours. | Ask about all OTCs with acetaminophen; increased toxicity from chronic use if heavy EtOH use, malnourishment, pre-existing liver disease—decrease maximum daily dose to 2 gm. |
| Salsalate | Salsalate: 500–750 mg bid; maximum dose 3000 mg/day. | Does not interfere with platelet function; GI bleeding & nephrotoxicity rare; salicylate concentrations can be monitored if toxicity suspected. |
| Choline magnesium trisalicylate | Choline magnesium trisalicylate: 750 mg tid; maximum dose 3000 mg/day. | |
| Tramadol | Start 25 mg daily; increase by 25–50 mg daily in divided doses every 3–7 days as tolerated to max dose of 100mg QID. Renal dosing (CRcl < 30 ml/min) 100mg bid. | Seizures and orthostatic hypotension. Other side effects similar to traditional opioids including sedation, confusion, respiratory depression. Potential for serotonin syndrome if patient is on other serotonergics such as triptans, duloxetine, and other antidepressants. |
| Hydrocodone/acetaminophen | 2.5/325 or 5/325–10/650 mg q4–6h; max acetaminophen dose 3gm/d. Consider recommending a supplementary dose of APAP 325 or 500 mg with combination dose for additional analgesia before increasing the opioid dose. | For all opioids, increased risk of falls in patients with dysmobility. May worsen or precipitate urinary retention when BPH present. Increased risk of delirium in those with dementia. Because of increased sensitivity to opioids older adults at greater risk for sedation, nausea, vomiting, constipation, urinary retention, respiratory depression, and cognitive impairment. Start stimulant laxative at first sign of constipation. Some might start at initiation if patient has existing complaints of constipation or other risk factors. |
| Oxycodone or morphine | 5–10 mg oxycodone q4h (begin with 2.5–5mg q4h) OR morphine 2.5–5 mg q4h; assess total needs after 7d on stable dose, then convert to long acting. | Side effects as per hydrocodone.Start stimulant laxative at first sign of constipation.NEVER start long acting opioid before determining needs with short acting. |
| Duloxetine | Start 20–30 mg/d; increase to 60 mg/d in 7 d. Not recommended in ESRD or CLcr <30. | May precipitate serotonin syndrome when combined with triptans, tramadol, and other antidepressants. Key drug-disease interactions: HTN, uncontrolled narrow-angle glaucoma, seizure disorder. Precipitation of mania in patients with bipolar disorder. Important adverse effects include nausea, dry mouth, sedation/falls, urinary retention, constipation. Contraindicated with hepatic disease and heavy alcohol use. Abrupt discontinuation may result in withdrawal syndrome. Contraindicated within 14 days of MAOI use |
*Abbreviations such as bid should be avoided in an effort to reduce errors.
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