Information on analgesia for Hypermobility Syndromes

HOWARD A. BIRD, MA MD FRCP
Professor of Pharmacological Rheumatology
University of Leeds
The General Infirmary at Leeds and Chapel Allerton Hospital
Leeds

The precise cause of pain in the joints in hypermobility syndromes is uncertain but experience suggests that analgesics represent the first choice in therapy. Paracetamol is the cheapest and safest in a dose of up to eight tablets a day. If this is inadequate the compound 'generic' analgesics Co Proxamol, Co Codamol and Co Dydramol should be tried, probably in that order. That still leaves Meptazinol and Tramadol in reserve. Each drug should be tried for an adequate period of time before being discarded as ineffective. There is unlikely to be much additional benefit by prescribing two of these at the same time.

Non steroidal anti-inflammatory drugs are a separate group, most rationally reserved for use on an 'as required' basis to remedy acute episodes of inflammation, notably when subluxation of a joint is followed by swelling and stiffness for a couple of days. Ideally NSAIDs of short half life are preferred in this situation, the generic preparations the longest established and the least expensive. These are Ibuprofen, Ketoprofen and Diclofenac, here arguably ranked in ascending order of potency (but also in ascending order of propensity to cause side effects), each acting for only a few hours after every dosing. Naproxen, with a longer half life, is dosed twice a day and Piroxicam, with the longest half life, once a day. If regular dosing is required, serious consideration should be given to a coxib such as Celebrex or Valdecoxib since, although more expensive, these have fewer gastrointestinal side effects.

In parallel, a nocturnal antidepressant used in doses lower than those used for the treatment of depression seems to improve pain tolerance during the day. Both Amitrityline and Dothiepin have a proven record in this respect though Amitrityline is more likely to cause side effects. SSRIs may play a role, as might other antidepressants. The evidence of benefit from Baclofen or Gabapentin is less convincing.

Oral medication can be supplemented by topical drugs, pasted over the affected joints. These could be analgesics (e.g. Traxam gel), NSAIDs (although a proportion of these will still be absorbed to cause side effects, even by the topical route) or counter irritants (e.g. Capsaicin). That leaves the more potent Fentanyl patches in reserve, providing they do not tear the skin if this is unduly fragile.

5 October 2004