What is the management for pain after Nexplanon (etonogestrel implant) placement?

Management of Pain After Nexplanon Placement

NSAIDs are the first-line treatment for pain after Nexplanon placement, with scheduled naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours being most effective when taken with food for the first 24-72 hours post-procedure. 1, 2

Pharmacological Management

First-Line Treatment

• NSAIDs:
  • Naproxen 440-550 mg every 12 hours OR
  • Ibuprofen 600-800 mg every 6-8 hours
  • Take with food to minimize gastrointestinal side effects
  • Continue on a scheduled basis for 24-72 hours post-procedure 1
  • Start before pain becomes severe for optimal effect

Second-Line Treatment

• Ketorolac (if pain is more severe):
  • 20 mg oral OR
  • 30 mg intramuscular
  • May be more effective than ibuprofen for acute procedural pain 1

Third-Line Treatment (for severe pain)

• Tramadol 50 mg:
  • Consider only if NSAIDs are ineffective or contraindicated
  • Patient may need transportation assistance due to sedative effects
  • Do not combine with benzodiazepines 1

Non-Pharmacological Management

• Heat therapy:

  • Apply heating pad or hot water bottle to the insertion site or lower abdomen 2
  • Can be used alongside NSAIDs for enhanced pain relief

• Acupressure:

  • Self-stimulation of acupressure points:
    • Large Intestine-4 (LI4): located on the dorsum of the hand between thumb and index finger
    • Spleen-6 (SP6): located approximately 4 fingers above the medial malleolus
  • Apply pressure bilaterally for several minutes 1, 2

• Relaxation techniques:

  • Deep breathing exercises
  • Guided imagery
  • Music therapy with slow-rhythm music 2

Special Considerations

When to Consider Implant Removal

• If pain persists beyond 72 hours despite optimal management
• If signs of allergic reaction develop (extremely rare but reported with barium sulfate component) 3
• If there is significant swelling, redness, or signs of infection at insertion site

Risk Factors for Complications

• Improper placement (especially sub-brachial fascia placement)
• Weight gain after placement
• Duration of implant placement >25 months 4

Follow-up Recommendations

• If pain persists beyond 72 hours despite appropriate management, evaluate for:
  • Improper placement
  • Local reaction or infection
  • Allergic response (rare)
• Most post-placement pain should resolve within 24-72 hours with appropriate management

Common Pitfalls to Avoid

• Waiting until pain is severe before starting NSAIDs
• Using inadequate dosing of pain medication
• Failing to combine pharmacological and non-pharmacological approaches
• Not considering rare allergic reactions when pain is accompanied by significant local inflammation

By following this algorithmic approach to pain management after Nexplanon placement, most patients will experience adequate relief with minimal side effects.