Expert panel consensus recommendations for the pharmacological treatment of acute pain in the Middle East region.

The findings of an expert panel convened to review critically how best to apply evidence-based guidelines for the treatment of acute pain in the Middle East region are presented. The panel recommended a three-step treatment protocol. Patients with mild-to-moderate levels of acute pain should be treated with paracetamol (step 1). If analgesia is insufficient after 1-2 days, a selective cyclo-oxygenase-2 inhibitor or, if gastrointestinal safety and bleeding risk are not an issue, a non-specific nonsteroidal anti-inflammatory drug, should be used (step 2). If analgesia remains inadequate, treatment with tramadol, or paracetamol plus codeine/tramadol is recommended (step 3). Patients reporting severe pain should be referred to a pain clinic or specialist for opioid analgesic treatment. Measures of pain and functioning that have been validated in Arabic, with culturally appropriate and easy to understand descriptors, should be used. Early and aggressive acute pain management is important to reduce the risk of pain becoming chronic, especially in the presence of neuropathic features.

Guidelines for the pharmacological treatment of peripheral neuropathic pain: expert panel recommendations for the middle East region.

Neuropathic pain (NeP) has been the focus of extensive basic and clinical research over the past 20 years. This has led to an increased understanding of underlying pathophysiological mechanisms and the development of new therapeutic agents, as well as a clearer definition of the role of established medications. To date there are no published treatment guidelines for NeP in the Middle East. A multidisciplinary panel of Middle East and international experts met to review critically and reach a consensus on how best to apply evidence-based guidelines for the treatment of NeP (mainly peripheral NeP) in the Middle East. The expert panel recommended pregabalin, gabapentin and secondary amine tricyclic antidepressants (nortriptyline and desipramine) as first-line treatments for peripheral NeP. Serotonin-norepinephrine reuptake inhibitor antidepressants, tramadol and controlled-release opioid analgesics were recommended as second-line treatments. There is a need to increase diagnostic awareness of NeP, use validated screening questionnaires and undertake more treatment research in the Middle East region.

[Medical treatment of venous priapism apropos of 46 cases: puncture, pharmacologic detumescence or penile cooling?]. / Traitement médical du priapisme veineux à propos de 46 cas: ponction, détumescence pharmacologique ou réfrigération pénienne?

OBJECTIVE: To analyse the efficacy of three nonspecific medical approaches to the first-line treatment of priapism : a) intracavernous injection (ICI) of alpha-adrenergic agonists, b) cavernous puncture, c) penile cutaneous cooling. METHODS: 46 cases of venous priapism, due to various aetiologies, were initially treated by ICI of alpha-adrenergic agonists (23 cases), puncture (14 cases) or cooling (9 cases). These 3 methods were combined only in the case of failure and not uniformly, based on our experience. The results were analysed in terms of successful detumescence and preservation of erectile function. RESULTS: Detumescence was obtained and erectile function was preserved in almost 80% of cases, with conservative treatment alone. ICI (83%) and cooling (78%) were more effective as first-line treatment than puncture (57%). The delay to treatment was a more important parameter than the aetiology. Cooling was no longer effective after the 8th hour, puncture was no longer effective after the 9th hour and ICI was no longer effective after the 34th hour. Failures of conservative treatment and erectile sequelae were only observed in cases of priapism treated after the 24th hour. CONCLUSION: The 3 methods have a similar degree of efficacy, provided they are performed early. Their indication depends on : 1) the duration of priapism, 2) the presence or absence of cavernosal anoxia. Schematically (and in parallel with aetiological treatment when possible) : a) in the case of painless priapism < 12 hours, cooling can be tried first, b) in the case of failure or painless priapism > 12, but < 24 hours, ICI of alpha-adrenergic agonists associated with puncture is indicated (except in the case of contraindications to ICI), c) in the case of painful priapism or > 24 hours, puncture must be the first treatment. In the case of failure, cavernosal blood gases should be performed to evaluate cavernosal anoxia and to guide management.