What are the ASH guidelines on the treatment of chronic pain in patients with sickle cell disease (SCD)?

Updated: May 12, 2021
  • Author: Joseph E Maakaron, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

For adults with chronic (as opposed to episodic) pain from the SCD-related identifiable cause of avascular necrosis of bone, ASH suggests use of duloxetine (and other serotonin and norepinephrine reuptake inhibitors [SNRIs], because there is evidence of a class effect) and NSAIDs as options for management, in the context of a comprehensive disease and pain management plan. ASH offers no recommendation for or against the use of SNRIs and/or NSAIDs for children in this setting.

For patients with SCD who have chronic (as opposed to episodic) pain from the SCD-related identifiable cause of leg ulcers, ASH does not offer a recommendation for or against any specific nonopioid pharmacological management strategy.

For adults who have SCD-related chronic pain with no identifiable cause beyond SCD, ASH suggests SNRIs (eg, duloxetine and milnacipran), tricyclic antidepressants (eg, amitriptyline), or gabapentinoids (eg, pregabalin) as options for pain management.

For patients with SCD and emerging and/or recently developed chronic pain that is refractory to multiple other treatment modalities, ASH suggests consideration of long-term opioid therapy, after risk stratification using a validated tool.

For patients who have chronic pain related to SCD, ASH suggests cognitive and behavioral pain management strategies in the context of a comprehensive disease and pain management plan.

For adults who have chronic pain related to SCD, ASH suggests other provider-delivered integrative approaches (eg, massage therapy and acupuncture) as available, 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.

For patients who have chronic pain related to SCD, ASH chooses not to offer a recommendation for or against a number of physical activities, exercise, or combined meditation/movement programs (including aerobic exercise, yoga, and Pilates) to improve pain and disability. ASH notes that if such interventions are considered, it requires shared decision-making that addresses feasibility, tolerability, acceptability, and patient experience and preference.


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