General Updates | Managing VOCs in patients with SCD: pharmacological and non-pharmacological approaches

So for vaso-occlusive crisis, the mantra is that we must believe the patient’s report of pain because we don’t have quantifiable objective biomarkers of painful crisis. So sometimes some patients do, if you follow the labs, you may find that some patients do have worse hemolysis when they are in crisis, lower hemoglobin, but these are not universally detectable changes in the common laboratory measures we have at our disposal. So it’s important to believe the patient. It’s important to treat the pain quickly – all guidelines recommend that the first dose of pain relief should be given within 30 minutes, and then the analgesia should be reassessed at frequent intervals with frequent redosing of opioids. Opioids are still the mainstay of treatment for acute pain. It’s also important to use a patient-controlled analgesia whenever possible for pain, and we know that this is a safer and more effective way to control pain. And ideally, patient-controlled analgesia should be available in the emergency department for those patients who are going to be hospitalized. Once the boluses have been completed, patients should be immediately transitioned to patient-controlled analgesia with which they can go to their respective floors. Unfortunately, that’s not always available, and sometimes between the emergency department and de-hospitalization, the admission to the floor, there is a gap in analgesia that is very problematic. 

It’s also well known that if you do have an infusion center or a day hospital, patients should ideally be treated in these types of settings rather than the emergency department because in the infusion center and the day hospital, there is a staff that is familiar with the patients and can provide the best care, the most empathic and holistic care. We know it’s also very important for each patient to have individualized care plans that have been developed specifically for them. So these are bespoke plans for each individual patient that take into account their tolerance to pain medications. They incorporate what has worked before and they should provide multiple instructions to the providers on not just opioids, but other supportive care and other medications to deal with the side effects of opioids. And they may also have specific information for each patient about allergies that might be important to their care. So this is very important. 

And so opioids are, again, are critical. In some patients, acetaminophen and non-steroidal anti-inflammatory drugs may also be helpful. We know that for some types of pain, non-steroidal anti-inflammatory drugs are beneficial, but it’s important to be mindful that kidney function tends to deteriorate as patients age. And so a lot of NSAIDs can contribute to deterioration of kidney function. Other pharmacological assets are medicines that target neuropathic pain, such as gabapentin, pregabalin, duloxetine, and others. These are beneficial for patients who have developed neuropathic pain. 

And then non-pharmacological approaches, unfortunately, are not as developed as they should be. But a lot of patients will tell you that applying warm compresses to areas of pain is beneficial. Resting, relaxation are also important. Rest and relaxation. Some patients do report that complementary medicine approaches with acupuncture or massage are also beneficial. But unfortunately, these approaches are not always available, they tend not to be covered by insurance. And so a lot of them are rarely available to patients who need it. But, you know, I’ve even heard that reiki is beneficial in some cases for patients with sickle cell disease. So these are all strategies that should be investigated in the future and actually should be investigated now, to be honest.

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