Choice of Analgesia in SJS/TEN

NSAIDS

• In most instances, Stevens-Johnson syndrome as a result of a nonsteroidal anti-inflammatory drug is drug-specific and therefore it is not universal that a patient will react to an alternative nonsteroidal
• NSAIDs are not automatically discontinued in cases of Stevens-Johnson syndrome unless one of them is suspected to be the cause
• no particular choice in this regard since although we do know that NSAIDS can cause Stevens-Johnson syndrome, we do not have enough data to distinguish those that might be "safer than others".
• During SJS or TEN management, NSAIDS should not be used unless other medicines, such as opioids or paracetamol, do not work

Opiods

• Pain control is an integral part of the management of SJS/TEN but there is not much literature available to guide one except for burn pain management.
• SJS/TEN patients experience background pain which is present at rest and is of low intensity.
• During procedures the pain is more intense and short-lived and the latter is referred to as procedural pain.
• Pain management has to be individualised, taking into consideration the clinical needs of the patient, viable route of administration, risk of respiratory suppression and monitoring facilities.
• In a non-ICU setting full consciousness is preferable as is oral therapy for reasons already mentioned.
• Oral transmucosal, short-acting, medium-potency opioids are best for procedural pain.
• Anxiolytics such as low-dose benzodiazepines can be added and these are more effective for patients with high pre-procedure anxiety and high baseline pain
• Longer-acting, mild- to moderate-potency opioids together with paracetamol should be given for background pain

Dosing Recomendations

Paracetamol

• children: 10-15 mg/kg orally every 4-6 hours when required, maximum 90 mg/kg/day
• adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Morphine Sulphate

• children: 0.05 to 0.2 mg/kg orally/intravenously every 2-4 hours when required, maximum 15 mg/kg; 
• adults: 7.5-10 mg orally/intravenously every 4 hours when required

Reference:

1. MANAGEMENT OF STEVENS-JOHNSON SYNDROME AND TOXIC EPIDERMAL NECROLYSIS. Current Allergy & Clinical Immunology, August 2007 Vol 20, No. 3
2. http://www.aaaai.org/ask-the-expert/stevens-johnson-syndrome.aspx
3. http://bestpractice.bmj.com.ezp.imu.edu.my/best-practice/monograph/237/treatment.html