Nonpharmacological therapies for chronic SCD pain Care Question : Should nonpharmacological therapies be used in addition to pharmacological therapy for the treatment of chronic pain in children and adults with SCD? 1. For adults and children with SCD who have chronic pain related to SCD, the ASH guideline panel suggests cognitive and behavioral pain management strategies in the context of a comprehensive disease and pain management plan (conditional recommendation based on very low certainty in the evidence about effects). Pain management in SCD-Specific hospital-based acute care setting Care Question: Should a hospital-based entity such as a day hospital or observation unit compared with regular ED care be used for children and adults with SCD who seek treatment for acute pain? 1. For adults and children who develop acute pain episodes requiring hospital care, the ASH guideline panel suggests using SCD-specific hospital-based acute care facilities (i.e., day hospitals and infusion centers, all with appropriate expertise to evaluate, diagnose, and treat pain and other SCD complications) over typical ED- based care (conditional recommendation based on low certainty in the evidence about effects). 2. For adults with SCD who have chronic pain related to SCD, the ASH guideline panel suggests other provider- delivered integrative approaches (e.g., massage therapy and acupuncture) as available and as tolerated and conditional upon individual patient preference and response. These approaches should be delivered in the context of a comprehensive disease and pain management plan (conditional recommendation based on very low certainty in the evidence about effects). Nonopioid pharmacological therapies for chronic SCD Pain with another identifiable cause Care Question : Should nonopioid pharmacological therapy, either in addition to or instead of opioids or other usual care interventions, be used for children and adults with SCD and chronic pain with another identifiable cause (e.g., avascular necrosis, leg ulcers)? 1. For adults with SCD who have chronic (as opposed to episodic) pain from the SCD-related identifiable cause of avascular necrosis of bone, the ASH guideline panel suggests the use of duloxetine (and other serotonin and norepinephrine reuptake inhibitor [SNRI] medications, because there is evidence of a class effect) as an option for management, in the context of a comprehensive disease and pain management plan (conditional recommendation based on very low certainty in the evidence about effects). 2. For adults with SCD who have chronic (as opposed to episodic) pain from the SCD-related identifiable cause of avascular necrosis of bone, the ASH guideline panel suggests the use of NSAIDs as an option for management, in the context of a comprehensive disease and pain management plan (conditional recommendation based on very low certainty in the evidence about effects). Nonopioid pharmacological therapies for chronic SCD pain with no identifiable cause Care Question : Should nonopioid pharmacological therapy, either in addition to or instead of opioids or other usual care interventions, be used for children and adults with SCD and chronic pain with no identifiable cause beyond SCD? 1. For adults who have SCD-related chronic pain with no identifiable cause beyond SCD, the ASH guideline panel suggests SNRIs (e.g., duloxetine and milnacipran)
Practice Research Program. The recommendations in this guideline are consistent with the theme of this course. Standardized protocol for acute scd pain in acute care setting Care Question : In children and adults who seek treatment of acute pain, should a standardized protocol be used that includes (1) reduced time to first dose (<1 hour from arrival) in addition to more frequent reassessment and dosing of pain medication (<30 minutes) and (2) tailored dosing (versus weight-based dosing)? 1. For adults and children with SCD presenting to an acute care setting with acute pain related to SCD for whom opioid therapy is indicated, the ASH guideline panel suggests tailored opioid dosing based on consideration of baseline opioid therapy and prior effective therapy ( for adults : conditional recommendation based on moderate certainty in the evidence about effects; for children : conditional recommendation based on low certainty in the evidence about effects). 2. For adults and children with SCD presenting to an acute care setting with acute pain related to SCD, the ASH guideline panel recommends rapid (within 1 hour of emergency department [ED] arrival) assessment and administration of analgesia with frequent reassessments (every 30-60 minutes) to optimize pain control (strong recommendation based on low certainty in the evidence about effects). Nonopioid pharmacological therapies for acute SCD pain Care Question : Should nonopioid pharmacological therapies either in addition to or instead of opioids or other usual care interventions be used for the treatment of acute pain in children and adults with SCD? 1. For adults and children with acute pain related to SCD, the ASH guideline panel suggests a short course (5 to 7 days) of nonsteroidal anti-inflammatory drugs (NSAIDs) in addition to opioids for acute pain management (conditional recommendation based on very low certainty in the evidence about effects). 2. For adults and children presenting for acute pain related to SCD, the ASH guideline panel suggests against corticosteroids for acute pain management (conditional recommendation based on low certainty in the evidence about effects). 3. For adults and children presenting with acute pain related to SCD who are hospitalized, the ASH guideline panel suggests a subanesthetic (analgesic) ketamine infusion as adjunctive treatment of pain that is refractory or not effectively treated with opioids alone (conditional recommendation based on very low certainty in the evidence about effects). 4. For adults and children presenting with acute pain related to SCD, the ASH guideline panel suggests regional anesthesia treatment approaches for localized pain that is refractory or not effectively treated with opioids alone (conditional recommendation based on very low certainty in the evidence about effects). Nonpharmacological therapies for acute SCD pain Care Question : Should nonpharmacological therapies in addition to pharmacological therapies be used for the treatment of acute pain in children and adults with SCD? 1. For adults and children who seek treatment for acute pain, the ASH guideline panel suggests massage, yoga, transcutaneous electrical nerve stimulation (TENS), virtual reality (VR), and guided audiovisual (AV) relaxation in addition to standard pharmacological management (conditional recommendation based on very low certainty in the evidence about effects).
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