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Seminar Exams > 1. NSAIDs, Acetaminophen > Flashcards

1. NSAIDs, Acetaminophen Flashcards

2016 RxPrep p657

1
Q

MOA of acetaminophen

A

Analgesic: thought to inhibit prostaglandin synthesis in the CNS and reduce pain impulse generation; may include the endogenous cannabinoid system and inhibit NMDA receptors
Antipyretic: mediated by inhibition of heat regulating centers in the brain
Lacks anti-inflammatory effects; does not inhibit thromboxane = no anti-platelet effects

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2
Q

acetaminophen (brand)

available as tablet/caplet, chewable tablet, ODT, injection, suspension, infant drops, suppository

A

Tylenol
Most “non-Aspirin” pain relievers
Ofirmev (IV)
FeverAll (rectal suppository)

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3
Q

acetaminophen dosing (for max/day, 325 mg, 500 mg, 650 mg, rectal suppository, and IV)

A

–Max: 4 g/day, 325 mg per Rx dosing unit in combo products
–325 mg: max 2 tab Q4-6h, NTE 10 tabs/day (3250 mg)
–500 mg: max 2 tab Q6h, NTE 6 tabs/day (3000 mg)
–650 mg ER: max 2 tab Q8h, NTE 6 tab/day (3900 mg)
–rectal supp: 650 mg Q4-6h, NTE 6 supp/day (3900)
–IV (for ≥50 kg): 650 mg Q4h (3900 mg) or 1g Q6h (4000 mg)

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4
Q

acetaminophen dosing (pediatrics)

A

–10-15 mg/kg Q4-6h; max 5 doses/day
–infant drops come in 160 mg/5 mL (like children’s suspension to avoid dosing confusion and toxicity risk)
–rectal supp: 80, 120, 325, 650 mg

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5
Q

acetaminophen BBW

A

May cause severe hepatotoxicity (potentially requiring liver transplant or resulting in death), usually associated with excessive acetaminophen intake (>4 g/day) or use of more than one acetaminophen containing product; risk of 10-fold dosing errors with injection

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6
Q

acetaminophen SEs

A

–Hepatotoxicity (possibly fatal)
–Severe skin rash (rare: SJS, TEN, AGEP - stop drug, seek immediate medical help)
–Nephrotoxicity (rare: usually with chronic overdose; generally safer than NSAIDs in renal disease)

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7
Q

acetaminophen is pregnancy category ___ (IV formulation)

A

C

often used for mild pain in pregnancy

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8
Q

avoid using ______ for acetaminophen on patient labels

A

APAP

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9
Q

acetaminophen safety consideration: use the _______ ____ or ______ provided with the medicine.

A

dosing syringe

cup

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10
Q

acetaminophen safety consideration: caution with IV acetaminophen. Concentration is 10 mg/mL (in 100 mL vials). Order in ___, not ____. Nurses should not be permitted to prepare doses; it should be prepared in the _____.

A

mg
mL
pharmacy

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11
Q

acetaminophen overdose:
–antidote: _________ (PO-Mucomyst, IV-Acetadote)
–MOA: restores [intra/extra]cellular ______
–administer immediately; even before the results of APAP level are obtained; within ___ hrs of ingestion
–Give ___ mg/kg PO loading dose, then ___ mg/kg PO Q4h x ___ doses (unless initial APAP level is non-toxic)
–Often causes N/V due to _____ of ______ ______

A 
–N-acetylcysteine (NAC) (IV is more costly)
–intra; glutathione
–8
–140; 70; 17
–odor; rotten eggs
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12
Q

acetaminophen DDI: [may/may not] be used with warfarin; chronic use of >__ g/day can increase INR

A

may

2

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13
Q

acetaminophen DDI: avoid or limit _____ use due to risk of hepatotoxicity

A

alcohol (1 drink/day for women; 2 drinks/day for men)

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14
Q

acetaminophen counseling point: should see Dr. if self-treating condition worsens, persists for more than ___ days, experiencing a high fever >____ºF, rash, N/V, or blood in stool; this applies for ______ as well; _____ should be seen by a pediatrician.

A

2
102.5
children
infants

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15
Q

MOA of NSAIDs

A

–non-selective: block synthesis of COX-1 (binds reversibly) and COX-2
–selective: block COX-2 only (decreasing GI risk)
–salicylates (aspirin): inhibits COX-1 irreversibly

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16
Q

COX-1 vs COX-2

A

–both enzymes catalyze the conversion of arachidonic acid
–COX-1: cytoprotective prostaglandins to protect GI mucosa; thromboxane to aid platelet aggregation
–COX-2: inflammatory prostaglandins sensitize skin pain receptors, recruit inflammatory molecules, regulate hypothalamic temperature control

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17
Q

NSAID BBW

A

a MedGuide is required to address GI and CV risks

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18
Q

all NSAIDs, including aspirin BBW: GI risk (define)
Can occur at any time during use and without warning. _____ patients, those with a hx of GI bleed, pts taking ______ and those taking ____/____ are at greatest risk for serious GI events

A

GI risk: bleeding, ulceration, perforation of stomach and intestines, which can be fatal
Elderly
corticosteroids
SSRIs/SNRIs

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19
Q

all non-aspirin NSAIDs BBW: CV risk (define)
Can occur in first few ____ of use. Risk may be increased with ____ doses or _____ duration of use and in patients with ___ disease or ____ _____ for it.

A 
CV risk: thrombotic events, MI, stroke, HF
weeks
higher
longer
CV
risk factors
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20
Q

non-aspirin NSAID CI

A

treatment of perioperative pain in the setting of CABG surgery

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21
Q

aspirin/acetylsalicylic acid (brand, dosing)

available as tablet/caplet, chewable tablet, suppository

A

Ascriptin, Bufferin, Ecotrin:
cardioprotection dosing 81-162 mg; analgesic dosing 325-650 mg Q4-6h
Durlaza (Rx): 162.5 mg daily

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22
Q

GI bleed s/sx

A

–dark, tarry stools
–stomach upset
–weakness
–coffee-ground emesis (indicates a more serious, fast GI bleed)

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23
Q

non-acetylated salicylates (5)

A 
–salsalate
–magnesium salicylate
–choline magnesium trisalicylate
–diflunisal
–salicylate salts
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24
Q

salsalate (brand, dosing)

A

generic only

up to 3 g/day divided BID-TID

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25
Q

magnesium salicylate (brand, dosing)

A

Doans, Doans ES, Momentum, Keygesic

ES: 580 mg/tab - 2 tab Q6h, NTE 8 tab/day

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26
Q

choline magnesium trisalicylate (brand, dosing)

A

generic only

1 g BID-TID or 3 g QHS

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27
Q

diflunisal (brand, dosing)

A

500 mg BID-TID; max 1.5 g/day

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28
Q

salicylate salts (brand, dosing)

A

Arthropan, Asproject, Magan, Mobidin, Resolate, Tusal

*no longer commonly used

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29
Q

NSAID warning: avoid with ______ hypersensitivity, nasal _____, asthma

A

NSAID

polyps

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30
Q

salicylate warning: avoid in ______ and teenagers with any _____ infection due to potential risk of ______ syndrome (Sx include _______, N/V, _______, confusion.

A 
children
viral
Reye's
somnolence
lethargy
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31
Q

NSAID warning: severe skin rash (rare) including ____/____.

A

SJS/TEN

Stop drug, seek immediate medical help

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32
Q

NSAID warning: upper GI events (ulcers), avoid if possible __-__ weeks before surgery due to _____ effects

A

1-2

antiplatelet

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33
Q

NSAID SEs:

A

dyspepsia, heartburn, bleeding, renal impairment, increased BP, CNS effects (fatigue, confusion, dizziness; caution in elderly), photosensitivity, fluid retention/edema, hyperkalemia (in renal impairment or with potassium-retaining agents), blurred vision

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34
Q

most NSAIDs are pregnancy category __ or __ (avoid, especially in the ___ trimester)

A

C or D

3rd

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35
Q

To decrease nausea with NSAIDs, use ___/______ product or take with _____.

A

EC/buffered

food

36
Q

____ may be used to protect the gut with chronic NSAID use; consider risks of their chronic use (2)

A

PPIs

decreased bone density, increased infection risk

37
Q

Do NOT use Durlaza when…

A

immediate effect is needed (e.g., MI)

38
Q

salicylate overdose can cause _____

A

tinnitus

39
Q

salicylates should be taken with food, water or milk to minimize ___ _____; all NSAIDs [should/can] be taken with food; salicylates usually cause [more/less] nausea

A

GI upset
should
more

40
Q

_____ salicylate is a popular OTC topical found in Bengay, Icy Hot, Flexal, Thera-Gesic, Salonpas

A

methyl

41
Q

ibuprofen (brand, dosing)

available as tablet/capsule, chewable tablet, suspension, injection

A

Motrin, Advil, Caldolor (IV)
OTC: 200-400 mg Q4-6h, max 1.2 g/day
Rx: 400-800 mg Q6-8h, max 3.2 g/day
higher doses required for inflammation

42
Q

ibuprofen self-treatment should be limited to ___ days

A

10

43
Q

ibuprofen dosing (pediatrics)

A

5-10 mg/kg/dose Q6-8h (as an antipyretic), max 40 mg/kg/day

44
Q

Caldolor IV injection: for mild-moderate pain, can decrease ____ dose; can be used when oral routes are not available; must be ______

A

opioid

diluted

45
Q

ibuprofen is similar to aspirin except for….

A

risk of Reye’s in children is not present (safe to use in pediatrics)

46
Q

Neoprofen injection is indicated for….

A

closure of patent ductus arteriosis (PDA) in premature infants

47
Q

naproxen (brand, dosing)

A

Aleve (OTC), Naprelan, Naprosyn, Anaprox
OTC (for pain, fever): 200 or 220 mg - 1 tab Q8-12h (may take 2 tab for 1st dose), NTE 3 tab/day
Rx: (for inflammation, mild-mod pain): 500 mg Q12h (or 250 mg Q6-8h); max 1250 mg on Day #1, then 1000 mg thereafter

48
Q

naproxen is sometimes preferred by prescribers and patients for its ___ dosing

A

BID

49
Q

naproxen base ____ mg = naproxen Na ____ mg

A

200

220

50
Q

The PPI in _____ is used to protect the gut from damage caused by the NSAID

A

Vimovo

51
Q

diclofenac (brand, dosing)

available as tablet/capsule, packet, gel, patch, topical solution, injection

A

Voltaren-XR, Dyloject (IV), Voltaren gel
PO tab: 50-75 mg BID-TID
IV: 37.5 mg Q6h

52
Q

diclofenac + misoprostol (Arthrotec) BBW

A

not to be used in women of childbearing potential unless woman is capable of complying with effective contraceptive measures

53
Q

oral diclofenac formulations are…

A

not bioequivalent even if mg strength is the same

54
Q

diclofenac + misoprostol note: misoprostol is used to replace gut-protective _______ to decrease risk of GI damage (was more popular before PPIs); increases ______ ______ and causes cramping and ______

A

prostaglandin
uterine contractions - which may terminate pregnancy!
diarrhea

55
Q

indomethacin (brand, dosing)

available as capsule, oral suspension, suppository, injection

A

Indocin, Tivorbex
IR: 20-50 mg BID-TID
CR: 75 mg daily-BID
Tivorbex: 20 mg TID, 40 mg BID-TID

56
Q

indomethacin has a high risk for ____ SEs and ___ toxicity

A

CNS (avoid in psych conditions)

GI

57
Q

indomethacin IR formulation is an older NSAID approved for _____; any NSAID can be used

A

gout

58
Q

Tivorbex is _______ for faster _______

A

micronized

dissolution

59
Q

indomethacin injection is indicated for ____ in premature infants

A

PDA

60
Q

piroxicam (brand, dosing)

A

Feldene

10-20 mg day

61
Q

piroxicam has a high risk for ___ toxicity and severe ____ reactions; use when other NSAIDs have ______; may need agent to protect ____

A

GI
skin
failed
gut (PPI, misoprostol)

62
Q

ketorolac (brand, dosing)

available as tablet, injection, nasal spray, ophthalmic

A

Toradol, Sprix (nasal spray), Acular (opthalmic)
PO: 10-20 mg x1, then 10 mg Q4-6h PRN; max 40 mg/day
IV (≥50 kg): 30 mg x1 or 30 mg Q6h
IM (≥50 kg): 60 mg x1 or 30 mg Q6h
Sprix:

63
Q

ketorolac parenteral doses should be decreased if ≥___ yo

A

65

64
Q

ketorolac: always start __, __, or ____ _____ and continue with ____, if necessary

A

IV
IM
nasal spray
oral

65
Q

ketorolac is not to be used in any situation with increased ______ risk

A

bleeding

66
Q

ketorolac BBW: for short-term ____ to ____ pain only as continuation of IV or IM ketorolac; max combined duration IV/IM and PO/nasal is ___ days in adults

A

moderate
severe
5

67
Q

ketorolac BBW: not for ______ or epidural use

A

intrathecal

68
Q

ketorolac BBW: CI in advanced ______ impairment or risk due to _____ depletion; decrease dose if ≥65 yo,

A

renal

volume

69
Q

ketorolac can cause severe adverse effects including GI bleeding and perforation, post-op bleeding, _____ _____ failure, ______ failure and ________ shock

A

acute renal
liver
anaphylactic

70
Q

ketorolac is used in [post/pre]-op, never [post/pre]-op

A

post

pre

71
Q

Sprix should be primed by spraying __ times before…

A

5

1st dose each day

72
Q

suldinac (brand, dosing)

is sometimes used with reduced ____ function and in patients on ____ requiring an NSAID

A

Clinoril
150-200 mg BID

renal
lithium

73
Q

COX-2 selective NSAIDs lower risk for ___ complications (but is still present), increase risk for ___/_____ (avoid with ___ risk, avoid in high doses and longer duration if use is necessary), same risk for _____ complications

A

GI
MI/stroke
CVD
renal

74
Q

What are the COX-2 selective NSAIDs? (4)

A

celecoxib (most selective)
meloxicam
etodolac
nabumetone

75
Q

celecoxib (brand, dosing, indications)

available as a capsule

A

CeleBREX
OA: 100 mg BID or 200 mg daily
RA: 100-200 mg BID
Indications: OA, RA, juvenile RA, acute pain, primary dysmenorrhea, ankylosing spondylitis

76
Q

celecoxib CI

A

with sulfonamide allergy

77
Q

celecoxib BBW

A

same as other NSAIDs

78
Q

celecoxib is pregnancy category __ prior to ___ weeks gestation and is category __ starting after

A

C
30
D

79
Q

meloxicam (brand, dosing)

available as tablet/capsule, oral suspension

A

Mobic: 7.5-15 mg daily
Vivlodex: 5-10 mg daily
(Vivlodex capsules and other meloxicam formulations are not interchangeable)

80
Q

etodolac (brand, dosing)

available as tablet/capsule

A

Lodine

300-500 mg Q6-8h

81
Q

nabumetone (brand, dosing)

available as tablet

A

Relafen

1000-2000 mg daily (can be divided BID)

82
Q

NSAID DDI: increased bleeding risk with…

A

other anticoagulants, antiplatelets, some herbals, SSRIs, SNRIs, thrombolytics, steroids (GI risk)

83
Q

NSAID DDI: use with other NSAIDs with one exception…

A

low dose aspirin for cardioprotection, but the cardioprotective effects may be blocked by ibuprofen and other NSAIDs - if aspirin needs to be taken for cardioprotection and ibuprofen for pain, take aspirin 1 hr before or 8 hrs after ibuprofen

84
Q

NSAID DDI: NSAIDs can increase levels of (2)

A

lithium (avoid concurrent use) and methotrexate

85
Q

NSAID DDI: caution with the use of aspirin and other _______ agents (aminoglycosides, IV loop diuretics, etc)

A

ototoxicity

86
Q 
NSAID counseling: 
–address bleeding, DDIs, GI and CV risk
–do not use after \_\_\_\_\_ \_\_\_\_ surgery unless instructed by doctor or after any elective surgery
–take with \_\_\_\_\_
–do not use if past allergy with NSAIDs
–may raise \_\_\_\_ \_\_\_\_\_
–may cause fluid and water to accumulate, particularly in \_\_\_\_\_
–photosensitivity
_do not use if \_\_\_\_\_\_\_\_
A 
coronary heart
food
blood pressure
ankles
pregnant

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