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Orthopedics Case No 7. Low Back Pain-1.

Mechanical low back pain:

✅কাদের হয়?

২০-৫০ বছর বয়সী মানুষদের জন্য সবচেয়ে কমন ব্যাক পেইন।

✅কি ফিচার নিয়ে প্রেজেন্ট করে?

১। সাডেন অনসেট এবং নড়াচড়া করলে ব্যাথা বাড়ে।

২। ফিজিক্যাল একটিভিটিতে ব্যাথা বাড়ে এবং রেস্টে কমে।

৩। ব্যাথা লোয়ার ব্যাক, বাটক এবং উরুর মধ্যে সিমাবদ্ধ থাকে। হাটুর নিচে নামবে না ব্যাথা।

৪। কোন ক্লিয়ার কাট নার্ভ রুট দিস্ট্রিনিউশিন থাকে না।

৫। Recurrent attack এর history থাকতে পারে।

৬। Systemic features absent থাকবে।

৭।Swelling absent থাকবে।

৮।prognosis good {৯০% রিকভার করবে ৬ সপ্তাহের মধ্যে।

✅inflammatory back pain এ exercise এ কমবে কিন্তু Rest এ বাড়বে।

✅এগজামিনেশনে কি ফাইন্ডিং পাবো?

*Asymmetrical paraspinal muscle tenderness থাকতে পারে এবং মুভমেন্ট কিছুটা restricted থাকতে পারে।

✅কি ইনিভেস্টিগেশন করতে দিব?

Acute attack: কোন ইনভেস্টিগেশন দরকার নাই।

MRI : যদি duration >6 weeks অথবা red flags থাকে ।

Plain Xray: যদি vertebral compression fracture, OA অথবা degenerative disc disease সাসপেক্ট করা হয়।

Additional …

ESR

CRP

electrophoresis

✅ট্রিটমেন্ট?

১।NSAID

Tablet 1.Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Indications of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Clofenac SR is indicated in-

Rheumatology: Inflammatory and degenerative forms of rheumatism, chronic involutive, polyarthritis, ankylosing spondylarthritis, osteoarthritis, spondylarthroses, acute gout, peri-articular rheumatic disorders.

Surgery and Traumatology: Sprain, bruises, dislocations, fractures, softtissue injuries, surgical interventions.

Obstetrics and Gynecology: Primary dysmenorrhoea, episiotomy, adnexitis, endometritis, parametritis, salpingitis, and mastitis.

Otorhinolaryngology: As pre-operative medication for the prevention of pain, inflammation, and swelling.

Dentistry: Post-operative and post-traumatic pain, inflammation, and swelling.

Other indications: For the prevention of pain and treatment of inflammation and swelling of patients operated in the urogenital tract, renal and biliary colic.

Pharmacology of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Dilofenac Sodium is a potent non-steroidal anti-inflammatory drug (NSAID) with pronounced anti-rheumatic, anti-inflammatory, analgesic and antipyretic properties. It has also some uricosuric effect. Diclofenac exerts its effect by inhibiting prostaglandin biosynthesis which plays a major role in causing inflammation, pain and fever. Diclofenac is rapidly and completely absorbed from the gastro-intestinal tract when taken with or after meal. Peak plasma concentrations are reached within an average of 2 hours after ingestion of it. At therapeutic concentrations, it is 99.7% bound to plasma proteins. Diclofenac is metabolized in the liver and undergoes first pass metabolism.

Dosage & Administration of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Diclofenac FC Tablet: Adults: 75-150 mg daily in 2 to 3 divided doses, preferably after food. Dose should be reduced in long term use.

Diclofenac SR Tablet:

  • Adult: 1 tablet daily, taken whole with liquid, preferably at meal times. If necessary, the daily dose can be increased to 150 mg by supplementation with conventional tablets.
  • Children: 1-3 mg of diclofenac/kg body wt. daily in divided doses.
  • Elderly patients: In elderly or debilitated patients, the lowest effective dosage is recommended, although the pharmacokinetics of diclofenac sodium is not impaired to any clinically relevant extent in elderly patients.

Diclofenac Dispersible Tablet:

  • Adults: The recommended daily dosage is 2-3 tablets and the maximum daily dose is 150 mg. In milder cases, 2 tablets of Diclofenac DT per day are sufficient. Diclofenac DT should preferably be taken before meals.
  • Children: Diclofenac is not recommended in children for other indications except juvenile rheumatoid arthritis where the recommended dose is 1-3 mg/kg body weight. Diclofenac DT is to be dropped into a half-glass of water and the liquid is to be stirred to aid dispersion before swallowing. There is no information on the use of Diclofenac DT for more than 03 months.

Diclofenac TR Capsule: One capsule daily. Diclofenac TR should be taken preferably after mealtimes.

Diclofenac Suppository: For adults: 50 mg suppository 2-3 times daily. Maximum daily dose is 150 mg.

Diclofenac injection: For adults the usual dose is 1 ampoule daily. In serious cases this dose may be increased up to 2 ampoules daily.

Diclofenac Gel: For external use only. Depending on the size of area to be treated, 2-4 g of Diclofenac gel should be applied to the skin 3-4 times daily. To the affected area gel should be rubbed in lightly. This gel may also be given in addition to further treatment with other dosage forms of Diclofenac.

Interaction

Clofenac SR may have the following drug interactions:

Lithium and digoxin: Clofenac SR may increase plasma concentrations of lithium and digoxin.

Anticoagulants: There are isolated reports of an increased risk of haemorrhage with the combined use of diclofenac and anticoagulant therapy, although clinical investigations do not appear to indicate any influence on anticoagulant effect.

Antidiabetic agents: Clinical studies have shown that diclofenac can be given together with oral antidiabetic agents without influencing their clinical effect.

Cyclosporin: Cases of nephrotoxicity have been reported in patients receiving cyclosporin and diclofenac concomitantly.

Methotrexate: Cases of serious toxicity have been reported when methotrexate and NSAIDs are given within 24 hours of each other.

Quinolone antimicrobials: Convulsions may occur due to an interaction between quinolones and NSAIDs.
Therefore, caution should be exercised when considering concomitant therapy of NSAID and quinolones.

Other NSAIDs and steroids: Co-administration of diclofenac with other systemic NSAIDs and steroids may increase the frequency of unwanted effects. With aspirin, the plasma levels of each is lowered, although no clinical significance is known.

Contraindications of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Contraindicated to the patients hypersensitive to any ingredient of the products. Peptic ulcer, hypersensitivity to Diclofenac like other non-steroid anti-inflammatory agents, Diclofenac is also contra-indicated in asthmatic patient in whom attack with asthma, urticaria or acute rhinitis are precipitated by acetylsalicylic acid or by other drugs with prostaglandin synthetase inhibitor. This Gel should not be used under occlusive airtight dressings.

Side Effects of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Clofenac SR is generally well tolerated. Adverse effects are mild, rare and transient. At the starting of the treatment, however, patients may be sometimes complaining of epigastric pain, eructation, nausea and diarrhea or dizziness or headache. These effects are usually mild in nature. Peripheral edema and skin reactions, such as rash and eczema have also been encountered. Clofenac SR Gel may cause local irritation and reddening of the skin and skin rash.

Pregnancy & Lactation

During pregnancy, Diclofenac should be employed only for compelling reasons. The lowest effective dose should be used. These types of drugs are not recommended during the first trimester of pregnancy. In view of insufficient clinical data, Diclofenac Sodium Gel is not recommended during pregnancy. A very insignificant quantity of Diclofenac may be detected in breast milk but no undesirable effects on the infant to be expected.

Precautions & Warnings

In rare instances where peptic ulceration or gastrointestinal bleeding occurs in patients under treatment with Clofenac SR. In patients with advanced age should be kept under close observation. Clofenac SR Gel should not be allowed to come in contact with the eyes or mucus membranes, after application the hands should be washed properly and not to be taken by mouth.

Therapeutic Class of Tablet :- Clofenac SR 100MG (Sustained Released) (AS A Diclofenac Sodium AS A Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)).

Drugs for Osteoarthritis, Drugs used for Rheumatoid Arthritis, Non-steroidal Anti-inflammatory Drugs (NSAIDs)

২।বেড রেস্ট হেল্পফুল না কারন এটা increase risk of chronic disability.

৩।physiotherapy.

৪।Low dose tricyclic antidepressants.(pain..sleep..mood)

Tablet 2.Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Indications of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Mig tablet is indicated for the treatment of-

  • Neuropathic Pain
  • Diabetic peripheral neuropathic pain (DPNP)
  • Postherpetic neuralgia (PHN)
  • Peripheral neuropathic pain (PNP)

Pharmacology of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Mirogabalin belongs to the class of gamma amino acids and its derivatives. Mirogabalin selectively binds α2δ subunits of voltage-gated calcium channels (VGCCs). It reduces calcium (Ca2+) influx and neurotransmission which inhibits neurotransmitter release in presynaptic neuron endings. Due to the inhibition of neurotransmitter release, the hyper- excitability of central nervous system (CNS) neurons decreases.

Mirogabalin is rapidly absorbed after oral administration; median time to maximum plasma concentration is 0.5-1.5h. Mirogabalin has a low plasma protein binding of approximately 25%. Mirogabalin has a mean apparent volume of distribution of 64-88L after single or multiple doses. The drug is cleared mainly unchanged (61-72%) via renal excretion by filtration and active secretion, however a slight fraction (13-20%) is metabolized by hepatic uridine 5′-diphospho-glucuronosyltransferase isoforms. The mean elimination half-life of mirogabalin observed 2-4.9h. 99% of mirogabalin is excreted through the kidneys, only 1% of the dose is excreted through feces.

Dosage & Administration of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Adult dose: The initial dose for adults is 5 mg of Mirogabalin twice daily. Then the dose is gradually increased by 5 mg at an interval of at least a week to 15 mg twice daily. The dose may be adjusted appropriately between 10 mg and 15 mg twice daily depending on ages and symptoms.

Use in Children and Adolescent: It is not known if Mirogabalin is safe and effective in children and adolescent.

Hepatic Impairment: A single 15 mg dose of Mirogabalin does not produce significant adverse reaction, in patients with mild to moderate hepatic impairment. No data available for severe hepatic impairment.

Renal Impairment: In mild renal dysfunction, the initial dose starts from 5 mg twice a day, slowly increased by 5 mg at an interval of 1 week to 10 mg. In moderate renal dysfunction, the initial dose starts from 2.5 mg twice a day, slowly increased by 2.5 mg at an interval of 1 week to 7.5 mg twice a day. In severe renal dysfunction, the initial dose starts from 2.5 mg once a day, slowly increased by 2.5 mg at an interval of 1 week to 7.5 mg once a day.

Interaction of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

With Medicine: Co-administration of Mig with Cimetidine or Probenecid may raise the Mig plasma concentration. Importantly, if Mig is taken with Lorazepam, the depressive effects on the CNS may be potentiated. Mig is OAT1, OAT3, OCT2, MATE1, MATE2-K and UGT substrate. Mig does not inhibit or induce major human CYP molecular species, and does not inhibit activities of drug transporters (including OAT1, OAT3, organic cation transporter OCT1, OCT2, OATP1B1, OATP1B3, MATE1, MATE2-K, P-gp and BCRP). Co-administrated with OAT1, OAT3, OCT2, MATE1, MATE2-K or UGT inhibitors may increase mirogabalin exposure, so use with caution.

With food & others: Administration of Mig with food has no clinically relevant effect on the total absorption of Mig. Avoid consuming alcohol while taking Mig, as Mig may potentiate the impairment of motor skills and sedating effects of alcohol.

Contraindications of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Mirogabalin is contraindicated in:

  • patients with hypersensitive to Mirogabalin.
  • patients with mild to moderate Hepatic & Renal impairment.

Side Effects of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

The most reported adverse reactions include somnolence, dizziness, edema and weight gain. The symptoms described below are rarely seen as initial symptoms of the adverse reactions indicated in brackets. If any of these symptoms occur, stop taking this medicine and see your doctor immediately.

  • Light headedness, state close to sleep with impaired consciousness, loss of consciousness (dizziness, somnolence, unconsciousness).
  • General malaise, loss of appetite, nausea, vomiting, jaundice (liver dysfunction).

Pregnancy & Lactation

For pregnant or potentially pregnant women, administer only if the therapeutic benefit outweighs the risks. Presence in placental passage has been reported in animal study. Consider the therapeutic and breastfeeding benefits then consider continuing or discontinuing breastfeeding. It has been reported in animal study that it is transferred into milk.

Precautions & Warnings

This medicine may cause dizziness, somnolence, or loss of consciousness. Avoid operating dangerous machinery, such as driving a car. Especially for elderly patients, careful attention should be taken. This medicine may cause weight gain. This medicine may cause blurred vision and double vision.

If an allergic reaction occurs, stop taking the medicine and consult with doctor. Dose adjustment is needed in patients with renal dysfunction. If taking any other medication, please consult with doctor before administering Mig. As this medicine may cause dizziness or somnolence, the patient should avoid operating in potentially hazardous activities such as driving a car. Elderly patients should be aware of falling and fracture. The patient should consult with the doctor if the signs of blurred vision or double vision appear while taking this medication.

Therapeutic Class of Tablet:-Mig 5 mg (AS A Mirogabalin Besylate AS A Adjunct anti-epileptic drugs, Primary anti-epileptic drugs)

Adjunct anti-epileptic drugs, Primary anti-epileptic drugs

Tablet 3.Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Indications of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Tryptin is indicated in-

  • Depressive Illness: particularly where sedation is required.
  • Nocturnal Enuresis in children.
  • Prophylaxis of Migraine.
  • Tension Headache.
  • Chronic Pain.

Description of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Tryptin is a tricyclic antidepressant. It has marked anticholinergic and sedative properties. It prevents the reuptake of noradrenaline and serotonin at the nerve ending. Tryptin is rapidly absorbed from the Gl tract. Peak plasma concentrations occur within 2-12 hours. Tryptin is excreted in the urine, mainly in the form of its metabolites.

Pharmacology of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

The mechanism of action of this drug is not fully elucidated. It is suggested that amitriptyline inhibits the membrane pump mechanism responsible for the re-uptake of transmitter amines, such as norepinephrine and serotonin, thereby increasing their concentration at the synaptic clefts of the brain. These amines are important in regulating mood. The monoamine hypothesis in depression, one of the oldest hypotheses, postulates that deficiencies of serotonin (5-HT) and/or norepinephrine (NE) neurotransmission in the brain lead to depressive effects. This drug counteracts these mechanisms, and this may be the mechanism of amitriptyline in improving depressive symptoms. Whether its analgesic effects are related to its mood-altering activities or attributable to a different, less obvious pharmacological action (or a combination of both) is unknown.

Dosage & Administration of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Depression: Initially 75 mg (Elderly and Adolescents 30-75 mg) daily in divided doses or as a single dose at bedtime increased gradually as necessary to 150-200 mg; Child under 16 years not recommended for depression.

Nocturnal Enuresis: Child 7-10 years: 10-20 mg, 11-16 years: 25-50 mg at night; max. period of treatment (including gradual withdrawal) 3 months-full physical examination before the further course.

Prophylaxis of Migraine: 100 mg daily.

Tension Headache: 10-25 mg three times daily.

Interaction

TCA enhances the sedative effect of alcohol and opioid analgesics. When TCA is used with Moxifloxacin or Terfenadine, it increases the risk of ventricular arrhythmias. Disulfirum and Cimetidine inhibit the metabolism of Tryptin. When TCA is used with diuretics, it enhances the risk of postural hypotension.

Contraindications

Amitriptyline is contraindicated in myocardial infarction, arrythmias, particularly heart block of any degree, mania and severe liver disease. Initially, sedation may affect the ability to drive or operate machinery.

Side Effects of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

  • Anticholinergic: Excessive perspiration, dry mouth, blurred vision, hyperpyrexia, urinary retention and urinary tract dilatation.
  • Cardiovascular reactions: Hypotension, syncope, postural hypotension, hypertension, tachycardia, palpitations, myocardial infarction, etc.
  • CNS and Neuromuscular: Confusional states, disturbed concentration, disorientation, delusions, etc.
  • Allergic: Skin rash, urticaria, photosensitization, etc.
  • Haematological: Bone-marrow depression.
  • Gastrointestinal: Nausea, epigastric distress, vomiting, anorexia, stomatitis, unpleasant taste, weight loss, diarrhoea, constipation, etc.
  • Endocrine: Testicular swelling, gynaecomastia, breast enlargement, galactorrhoea, etc.

Pregnancy & Lactation of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Pregnancy Category C. Amitriptyline has been shown to cross the placenta. Amitriptyline should be used during pregnancy only if the potential benefit to the mother justifies the potential risk to the fetus. Amitriptyline is excreted into breast milk. Because of the potential for serious adverse reactions in nursing infants from Amitriptyline, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Precautions & Warnings

It should be used with caution in patients with a history of epilepsy, glaucoma, urinary retention, cardiac disease, diabetes, pregnancy, hepatic impairment, thyroid disease, increased intra-ocular pressure and psychoses (may aggravate mania).

Therapeutic Class of Tablet:-Tryptin 10 mg (AS A Amitriptyline Hydrochloride AS A Tricyclic Anti-depressant).

Tricyclic Anti-depressant

✅✅reference *DAVIDSON..

Raiyyan Tahsan ❤️Date:-06-02-2025 Thursday Time:-11-05-20.Pm

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