**4.4 Fibromyalgia**

*Pain Management - Practices, Novel Therapies and Bioactives*

• codeine 30 mg + paracetamol 500 mg,

• codeine 30 mg + ibuprofen 400 mg,

• ibuprofen 150 mg + paracetamol 500 mg,

• tramadol 37.5 mg + paracetamol 325 mg,

• tramadol 75 mg + dexketoprofen 25 mg, and

• oxycodone 5 mg (10 and 20 mg) + paracetamol 325 mg.

MP are [19]:

is necessary [19].

**4.2 Osteoarthritis (OA) pain**

analgesia in OA patients [21].

**4.3 Back pain**

The main pharmacological associations currently available for the treatment of

For all these combinations, careful monitoring must be performed in order to assess whether continuation of therapy, suspension, or transition to a strong opioid

Pain associated with rheumatologic conditions has a strong peripheral nociceptive component, although recent data also suggest a central sensitization [37]. Ideal treatment of rheumatic pain should be through a multimodal approach, integrating non-pharmacologic and pharmacologic treatments [38]. In the context of rheumatological painful conditions, the association of dexketoprofen and tramadol may represent an attractive medication for acute exacerbations of OA pain, due to its pharmacological profile: the combination of dexketoprofen and tramadol, targeting different sites of action, is suitable for OA type of pain, arising from different body structures (joints, muscles, ligaments, etc.) [21]. The rapid onset of analgesic effect of dexketoprofen, with its anti-inflammatory activity, associated to the sustained action of tramadol, makes their combination a valuable tool to achieve multimodal

Back problems are the third reason for seeking medical help, with about 90% of people suffering from them at some point in their lives [39, 40]. Most episodes of back pain are short lasting with little or no consequence, but recurrent episodes are common and back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences [41]. The complexity of chronic back pain management highlights the need for early intervention in patients with acute back pain in order to prevent progression to chronic back pain [42]. Chronic low back pain has been shown to be secondary to both neuropathic and nociceptive pain mechanisms [43]: a multimodal approach is therefore appropriate. The pain treatment armamentarium for both acute and chronic back pain includes NSAIDs, opioids, steroids, topical medicines, and adjuvants: the choice of medication depends on a number of factors, including the duration of symptoms, severity of symptoms, expected benefits, prior response to medications, adverse effect profile, presence of comorbidities, costs, and degree of supporting evidence [44]. Most guidelines endorse (NSAIDs) and weak opioids for short periods when there is contraindication or lack of improvement with

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NSAIDs [45].

Fibromyalgia is mainly a centralized pain disorder, accompanied by fatigue, sleep disturbance, and memory and mood difficulties [43]. Effective drugs combinations for this condition include tramadol + paracetamol [46], cyclobenzaprine + fluoxetine [47], pregabalin added to either quetiapine or trazodone [48], and fluoxetine + amitriptyline [49].
