The combination of Meloxicam, Paracetamol and Tramadol as a top up covers just about every scenario. For surgery – Local Infiltration Analgesia, or LIA (Ropivicaine, Ketorolac, Dexamethasone, and Adrenaline) is critical.  Norspan (Buprenorphine 5ug/hr) for knee replacements, posterior approach to the hips seems to help and avoid peaks and troughs in pain control.  A little Amitriptyline for rare neuropathic pain is useful.  But I wonder whether the narcotics crowd has fanned the anxieties of prescribers, making narcotics the easy solution for doctors?

I accept that Tramadol is also potentially addictive, but I found a decade ago when I swapped using Endone to Tramal, that my patients no longer required another five boxes, but were likely to use just a bit over one box after knee replacement surgery.  Tramal is much less addictive than Endone.

Some surgeons are preferring Tapentadol – although I wonder whether less serotonergic effect is actually better, and the fast acting option is not covered by the Pharmaceutical Benefits Scheme.  Nausea is unlikely if the patients if the starting dose is 50mg at a time, and the patients actually have enough pain to justify it.  Hallucinations do rarely occur, in which case we swap to something else.  

Interaction with SSRI’s (Selective serotonin reuptake inhibitors) is rare – serotonin syndrome with normal doses of SSRIs or SNRIs (Serotonin and norepinephrine reuptake inhibitors) and normal doses of Tramal have not been observed by this author despite being used in hundreds of cases.  The more depressed a patient is – the more they should avoid narcotics!

In the instance of joint replacement surgery – Torodol (ketorolac) is administer in the periarticular mix intra-operatively, and directly into the joint via a wound catheter with a 0.4um filter after surgery.  The evening dose is for morning patient, the morning after dose is received by all patients. The Mobic (meloxicam) is used typically for three weeks for hip and knee replacements.

We remeasured the eGFR in patients after surgery if their preoperative eGFR was abnormal.  The graph below is of 63 patients who had a followup eGFR in the two years prior to February 2018.  We note a dip in eGFR on day one after surgery, then recovery.  We’ll collect more data and hopefully get it into a peer reviewed journal.