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228 Chapter 7 Pain Assessment and Management in Children

Table 7-6

Coanalgesic Adjuvant Drugs

DRUG DOSAGE INDICATIONS COMMENTS
ANTIDEPRESSANTS
Amitriptyline 0.2-0.5 mg/kg PO hs Continuous neuropathic pain with Provides analgesia by blocking reuptake of serotonin
Titrate upward by 0.25 mg/kg every 5-7 days prn burning, aching, dysthesia with and norepinephrine, possibly slowing
Available in 10- and 25-mg tablets insomnia transmission of pain signals
Usual starting dose: 10-25 mg Helps with pain related to insomnia and depression
(use nortriptyline if patient is oversedated)
Analgesic effects seen earlier than antidepressant
effects
Nortriptyline 0.2-1.0 mg/kg PO AM or bid Neuropathic pain as above without Side effects include dry mouth, constipation, urinary
Titrate up by 0.5 mg every 5-7 days insomnia retention.
Maximum: 25 mg/dose
ANTICONVULSANTS
Gabapentin 5 mg/kg PO at bedtime Neuropathic pain Mechanism of action unknown
Increase to bid on day 2, tid on day 3 Side effects include sedation, ataxia, nystagmus,
Maximum: 300 mg/day dizziness
Carbamazepine 6 yr: Sharp, lancinating neuropathic pain Similar analgesic effect to amitriptyline
2.5-5 mg/kg PO bid initially Peripheral neuropathies Monitor blood levels for toxicity only
Increase 20 mg/kg/24 hr, divide bid every week prn Phantom limb pain Side effects include decreased blood counts, ataxia,
Maximum: 100 mg bid gastrointestinal irritation
6 to 12 years:
5 mg/kg PO bid initially
Increase 10 mg/kg/24 hr divide bid every week prn
to usual max: 100 mg/dose bid
12 years:
200 mg PO bid initially
Increase 200 mg/24 hr, divide bid every week prn to
max: 1.6-2.4 g/24 hr
ANXIOLYTICS
Lorazapam 0.03-0.1 mg/kg every 4-6 hr PO or IV Muscle spasm May increase sedation in combination with opioids
Maximum: 2 mg/dose Anxiety Can cause depression with prolonged use
Diazapam 0.1-0.3 mg/kg every 4-6 hr PO or IV
Maximum: 10 mg/dose
CORTICOSTEROIDS
Dexamethasone Dose dependent on clinical situation; higher bolus Pain from increased intracranial Side effects include edema, gastrointestinal irritation,
doses in cord compression, then lower daily dose pressure increased weight, acne
Try to wean to NSAIDs if pain allows Bony metastasis Use gastroprotectants such as H2-blockers
Cerebral edema: 1-2 mg/kg load then 1-1.5 Spinal or nerve compression (ranitidine) or proton pump inhibitors such as
mg/kg/day divided every 6 hr omeprazole for long-term administration of
Maximum: 4 mg/dose steroids or NSAIDs in end-stage cancer with
Antiinflammatory: 0.08-0.3 mg/kg/day divided bony pain
every 6-12 hr
OTHERS
Clonidine 2-4 mcg/kg PO every 4-6 hr Neuropathic pain
2-Adenoreceptor agonist modulates ascending pain
May also use a 100 mcg transdermal patch every 7 Lancinating, sharp, electrical, sensations
days for patients 40 kg (88 lb) shooting pain Routes of administration: oral, transdermal, and
Phantom limb pain spinal
Management of withdrawal symptoms
Monitor for orthostatic hypertension, decreased
heart rate
Sedation common
Mexiletine 2-3 mg/kg/dose PO tid, may titrate Similar to lidocaine, longer acting
0.5 mg/kg every 2-3 wk prn Stabilizes sodium conduction in nerve cells, reduces
Maximum: 300 mg/dose neuronal firing
Can enhance action of opioids, antidepressants,
anticonvulsants
Side effects include dizziness, ataxia, nausea, vomiting
May measure blood levels for toxicity
bid, Twice a day; IV, intravenous; NSAIDs, nonsteroidal antiinflammatory drugs; PO, by mouth; prn, as needed; tid, three times a day.

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