Pharmacological pain management in chronic pancreatitis

Abstract

Intense abdominal pain is a prominent feature of chronic pancreatitis and its treatment remains a major clinical challenge. Basic studies of pancreatic nerves and experimental human pain research have provided evidence that pain processing is abnormal in these patients and in many cases resembles that seen in neuropathic and chronic pain disorders. An important ultimate outcome of such aberrant pain processing is that once the disease has advanced and the pathophysiological processes are firmly established, the generation of pain can become self-perpetuating and independent of the initial peripheral nociceptive drive. Consequently, the management of pain by traditional methods based on nociceptive deafferentation (e.g., surgery and visceral nerve blockade) becomes difficult and often ineffective. This novel and improved understanding of pain aetiology requires a paradigm shift in pain management of chronic pancreatitis. Modern mechanism based pain treatments taking into account altered pain processing are likely to increasingly replace invasive therapies targeting the nociceptive source, which should be reserved for special and carefully selected cases. In this review, we offer an overview of the current available pharmacological options for pain management in chronic pancreatitis. In addition, future options for pain management are discussed with special emphasis on personalized pain medicine and multidisciplinarity.

Keywords: Chronic pancreatitis, Pain, Treatment, Pharmacology, Analgesics, Adjuvant analgesics

Core tip: Pharmacological pain management in chronic pancreatitis is complicated and requires a multidisciplinary approach. Identification of risk factors associated with disease progression and evaluation of extra pancreatic causes of pain and complications is essential in all patients. Analgesics are typically titrated according to the World Health Organization ladder principle, but in some situations a top-down approach may be useful to control pain and avoid sensitization of central pain pathways. Adjuvant analgesics and combinations of drugs should be considered at an early stage. Non-encapsulated enzyme therapy, somastotatin-analogues and antioxidants can be considered as supplements to conventional analgesics in special situations.