What are the treatment options for different types of pain in general practice in India, including brand name medications like Calpol (Paracetamol) and Brufen (Ibuprofen)?

Treatment Options for Different Types of Pain in General Practice in India

Paracetamol (Calpol) and Ibuprofen (Brufen) are the cornerstone medications for managing mild to moderate pain in general practice in India, with selection based on pain intensity, patient characteristics, and underlying cause.

Pain Assessment and Classification

Pain should be assessed using standardized tools like:

• Numerical Rating Scale (NRS): 1-10 scale
• Pain categorization:
  • Mild pain: NRS 1-4
  • Moderate pain: NRS 5-7
  • Severe pain: NRS >7 1

Treatment Algorithm Based on Pain Intensity

Mild Pain (NRS 1-4)

• First-line: Paracetamol (Calpol) 500-1000 mg every 6 hours, maximum 4000 mg/day 1, 2

  • Preferred by 77% of general practitioners, 78.57% of consulting physicians, and 74% of surgeons in India 3
  • Advantages: Minimal GI effects, safe in most patients
  • Caution: Reduce dose in liver disease

• Alternative: Ibuprofen (Brufen) 200-400 mg every 6-8 hours, maximum 2400 mg/day 1, 4

  • Advantages: More effective than paracetamol for many pain conditions 5
  • Caution: GI protection recommended for prolonged use

Moderate Pain (NRS 5-7)

• First-line: Paracetamol + Tramadol combination 3

  • Preferred by 77% of GPs, 87.5% of consulting physicians, and 80.3% of orthopedicians in India
  • Dosage: Typically 325-500 mg paracetamol with 37.5-50 mg tramadol

• Alternative: Paracetamol + Ibuprofen combination 6

  • Common combinations: Ibuprofen 200 mg/Paracetamol 500 mg or Ibuprofen 400 mg/Paracetamol 1000 mg
  • Superior efficacy compared to either drug alone 6, 7
  • Used by 68.94% of orthopedicians in India 3

Severe Pain (NRS >7)

• First-line: Strong opioids (e.g., morphine) + non-opioid analgesics 1, 2

  • Starting dose: Oral morphine 20-40 mg/day divided every 4 hours
  • Should include breakthrough pain medication (10-15% of total daily dose)

• Alternative: Transdermal fentanyl for stable pain 1, 2

  • Not recommended as first-line for patients who can swallow
  • Useful for patients with poor compliance or inability to take oral medications

Pain-Specific Treatment Approaches

Neuropathic Pain

1. First-line: Gabapentin 1

   • Titrate to 2400 mg per day in divided doses
   • Brand names in India: Gabapin, Gabtin, Neurontin

2. Second-line options:

   • Duloxetine (Duzela, Dulane) 60 mg once daily 1
   • Pregabalin (Pregeb, Lyrica) for post-herpetic neuralgia 1
   • Amitriptyline (Amitone) 10-25 mg at bedtime, titrate slowly 1

3. Topical therapy: Capsaicin cream for peripheral neuropathic pain 1

Musculoskeletal Pain

1. First-line: NSAIDs 2, 4

   • Ibuprofen (Brufen) 400 mg three times daily
   • Diclofenac (Voveran) 50 mg three times daily
   • Naproxen (Naprosyn) 250-500 mg twice daily

2. For chronic conditions: Consider cyclooxygenase-2 (COX-2) inhibitors with caution 1

Cancer Pain

Follow WHO analgesic ladder 1, 2:

1. Step 1 (Mild pain): Non-opioid analgesics
2. Step 2 (Moderate pain): Weak opioids + non-opioids
3. Step 3 (Severe pain): Strong opioids + non-opioids

Important Considerations for Analgesic Selection

Patient Factors to Consider

1. Age: Most important factor cited by 72.8% of GPs, 74.4% of dentists, and 87.5% of consulting physicians 3

   • Elderly: Start with lower doses, especially of opioids and NSAIDs 2

2. Duration of therapy: Critical factor for 70.8% of GPs and 73.6% of surgeons 3

   • Short-term: Standard dosing
   • Long-term: Consider side effect profiles, add gastroprotection with NSAIDs

3. Comorbidities:

   • Renal impairment: Avoid or use reduced doses of NSAIDs 2
   • Liver disease: Reduce paracetamol dosage 2
   • Cardiovascular disease: Caution with NSAIDs 1

Common Pitfalls to Avoid

1. Overreliance on OTC medications: 68% of Indian patients self-medicate with OTC drugs, primarily NSAIDs (95%) 8

2. Inadequate pain specialist referral: 38.8% of practitioners cite lack of pain clinics as reason for not referring patients 3

3. Inadequate breakthrough pain management: Ensure rescue doses (10-15% of total daily opioid dose) are prescribed 2

4. Neglecting non-pharmacological approaches: Consider physical therapy, heat therapy, and other modalities 2

Brand Names of Common Pain Medications in India

Paracetamol

• Calpol (GlaxoSmithKline)
• Dolo (Micro Labs)
• Paracip (Cipla)
• Febrinil (Alkem)

NSAIDs

• Brufen (Abbott) - Ibuprofen
• Voveran (Novartis) - Diclofenac
• Combiflam (Sanofi) - Ibuprofen + Paracetamol
• Naprosyn (RPG Life Sciences) - Naproxen

Opioids

• Tramadol brands: Tramazac, Tramacip
• Combination brands: Ultracet (Tramadol + Paracetamol)

Neuropathic Pain Medications

• Gabapentin: Gabapin, Gabtin, Neurontin
• Pregabalin: Pregeb, Lyrica, Pregabalin
• Duloxetine: Duzela, Dulane, Cymbalta