Table 3.

European recommendations for the pharmacological management of acute and chronic pain [19]

Children		Adults
Acute pain	Chronic pain	Acute pain	Chronic pain*
1. Paracetamol†	1. Paracetamol† ± adjuvant treatment	a. Without comorbidities	a. Without comorbidities
2. Paracetamol† + weak opioid	2. Paracetamol† + weak opioid	1. Paracetamol† ± adjuvant treatment	1. Paracetamol†
3. Opioids in hospital setting	3. Refer to pain specialist	2. Paracetamol† + weak opioid or metamizol or COX-2-selective NSAID	2. COX-2-selective NSAID or nonselective NSAID ± PPI or paracetamol + weak opioid
		3. Tramadol or strong opioids	3. Tramadol or strong opioids ± nonopioid
		b. With liver dysfunction	b. With mild-to-moderate liver dysfunction
		1. Liver function should be carefully surveyed when using paracetamol and metamizol	1. Liver function should be carefully monitored when using paracetamol and metamizol
		2. Maximum doses should be reduced according to prescription guidelines	2. Maximum doses should be reduced according to prescription guidelines
			3. Use COX-2-selective or nonselective NSAIDs ± PPI only in patients with mild chronic liver disease (monitor renal function)
			c. With cardiovascular disease/risk
			1. Use all NSAIDs with caution
			2. If using NSAIDs, the least COX-2-specific drugs (e.g. naproxen, or ibuprofen) should be preferred. Consider coprescribing a PPI
			3. Avoid long-term NSAID use

Nonvalidated recommendations based on general pain management guidelines, the experience of surveyed HTCs of the EHTSB, and consensus achieved following board discussion. The recommendations reflect the WHO pain ladder approach (i.e. subsequent steps are employed when the previous one has failed).

^*Adjunctive antidepressants or anticonvulsants should be considered.

^†Risk of acute hepatotoxicity with very high doses of paracetamol, especially in patients with liver disease.

COX-2, cyclooxygenase-2; EHTSB, European Haemophilia Therapy Standardisation Board; HTC, haemophilia centre; PPI, proton pump inhibitor.