Analgesic Management in Acute Pancreatitis

Morphine is the first-line analgesic for acute pancreatitis pain management, with hydromorphone preferred in non-intubated patients. 1, 2

Pain Assessment and Initial Management

Pain in pancreatitis should be regularly assessed using validated tools such as visual analog scales (VAS), verbal rating scales (VRS), or numerical rating scales (NRS) 1
Pain in pancreatitis often has both visceral and neuropathic components due to proximity to the celiac axis 1, 3
All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 4, 5

For mild pain: Start with NSAIDs with or without paracetamol (acetaminophen) 1
For moderate pain: Use weak opioids such as codeine or tramadol in combination with non-opioid analgesics 1, 3
For severe pain: Morphine is the first-line opioid choice 1, 2
- Initial dosing for morphine: 0.1 mg to 0.2 mg per kg every 4 hours as needed 2
- Administer IV morphine slowly to avoid chest wall rigidity 2
In non-intubated patients, hydromorphone may be preferred over morphine 1, 3

Recent randomized controlled trials have shown that opioids are more effective than NSAIDs for pain relief in acute pancreatitis 6, 7
Buprenorphine demonstrated superior pain relief compared to diclofenac, requiring significantly less rescue fentanyl (130 μg vs 520 μg) 7
Pentazocine (an opioid) was found to be better than diclofenac for pain relief in acute pancreatitis, requiring less rescue fentanyl 6
A systematic review and meta-analysis found that opioids were associated with a decreased need for rescue analgesia compared to non-opioids (OR 0.25,95% CI 0.07 to 0.86) 8

For neuropathic pain components, consider gabapentin, pregabalin, nortriptyline, or duloxetine 1, 3
When medications provide inadequate relief or cause intolerable side effects, consider celiac plexus block 1, 3

Laxatives must be routinely prescribed for both prevention and management of opioid-induced constipation 1, 3
Metoclopramide and antidopaminergic drugs are recommended for treatment of opioid-related nausea/vomiting 1, 3

Use opioids with caution, at reduced doses and frequency in patients with renal impairment 1, 3, 2
Fentanyl and buprenorphine are safer options for patients with chronic kidney disease stages 4 or 5 1, 3
Morphine is contraindicated in patients with respiratory depression in the absence of resuscitative equipment, acute or severe bronchial asthma, hypercarbia, or paralytic ileus 2
Have naloxone injection and resuscitative equipment immediately available when administering morphine 2

Ensure adequate fluid resuscitation as part of pain management 1
The nasogastric route for feeding can be used as it appears to be effective in 80% of cases when nutritional support is required 4, 5
Monitor patients closely for signs of respiratory depression, especially in elderly or debilitated patients 2
Adjust dosing regimen for each patient individually, taking into account prior analgesic treatment experience, opioid tolerance, and general medical status 2