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ANESTHESIA > 20 – Miscellaneous Analgesic Drugs > Flashcards

20 – Miscellaneous Analgesic Drugs Flashcards

1
Q

Nontraditional analgesic agents: are often classified as adjuvant analgesics to

A
  • Potentiate effect of traditional analgesics
  • Reduce dose and side effects of primary drugs
  • *part of multimodal treatment plan
  • *used to treat acute AND chronic (neuropathic) pain
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2
Q

Chronic pain

A
  • Pain that has persisted beyond normal tissue healing time
  • *without apparent biological value
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3
Q

What are the two components of chronic pain

A
  • Inflammatory pain
  • Neuropathic pain
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4
Q

Neuropathic pain is pain caused by a

A
  • Disease or lesion which leads to damage or dysfunction of somatosensory (pain) system
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5
Q

Neuropathic pain can lead to

A
  • Abnormal pain sensations
    o Hyperalgesia
    o Allodynia
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6
Q

Example of neuropathic pain in a cat post-amputation

A
  • First: hiding and inappropriate urination
  • Second: non mobility without falling over, very LETHARGIC
  • *phantom limb pain
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7
Q

Phantom limb pain is

A
  • A complex neuropathic pain syndrome
  • *excessive pain conditions: allodynia and hyperalgesia
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8
Q

Phantom limp pain is associated with

A
  • Direct nerve injury
  • Central sensitization
  • Changes in cortical recognition of pain and sensation
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9
Q

‘steps’ of phantom limp pain

A
  • Excessive c-fiber firing
  • Result in ongoing dorsal horn stimulation
  • Stimulation of NMDA receptors
  • Development of new sympathetic nerve fibers
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10
Q

Antiepileptic drugs: examples (2)

A
  • Gabapentin
  • Pregabalin
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11
Q

Gabapentin

A
  • Treatment for seizures and neuropathic pain
  • Structural analogue of GABA with little activity on GABA receptor
  • *also acts on descending noradrenergic inhibitory system
  • Dose and administration frequency vary among individuals
  • High, but VARIABLE oral bioavailability
  • NOT linear pharmacokinetics
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12
Q

Gabapentin blocks

A
  • Calcium influx into presynaptic membrane by inhibition of voltage-gated calcium channels=decreased release of excitatory NTs
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13
Q

Gabapentin is available as

A
  • Capsules
  • Tablets
  • Liquid
  • *avoid formulations with xylitol (human formulations)
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14
Q

Gabapentin elimination half life

A
  • 3-4hrs
  • *need frequent oral dosing (3x/day)
  • *work with client to find dose and administration frequency
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15
Q

Gabapentin dose range

A
  • 3-20mg/kg BID-TID
  • *6-8 hrs (12 hours showed POOR response)
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16
Q

What was the most common side effect of gabapentin that owners reported?

A
  • *sedation
  • ataxia
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17
Q

Take home message of gabapentin to minimize adverse events

A
  • Start with lower dose that could be titrated up until a balance between sedation and efficacy is achieved
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18
Q

Gabapentin in humans

A
  • May be good for acute pain
  • Single dose reduced opioid consumption post op
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19
Q

Pregablin

A
  • Similar structure to gabapentin, but has HIGHER oral bioavailability
    o Potential more effective
  • Linear pharmacokinetics
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20
Q

Pregablin dose in cats and dogs

A
  • Cats: 1-2mg/kig BID (sedation at 4mg/kg)
  • Dogs: 4mg/kg BID
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21
Q

NMDA receptors location

A
  • Dorsal horn of spinal cord
22
Q

NMDA receptors are activated by

A
  • Excitatory NTs (glycine and glutamate) during SUSTAINED nociception in dorsal horn
  • *activations occurs mostly in maladaptive (chronic) and NOT in acute pain
23
Q

NMDA receptors are key players in

A
  • Central sensitization and wind-up
24
Q

What drugs can antagonize NMDA receptors to produce ANITHYPERALGESIC effects?

A
  • Amantadine
  • Subanesthetic doses of ketamine
25
Q

Ketamine

A
  • Subanesthetic dose used for analgesia/antihyperalgesia
  • NOT considered a stand-alone analgesic (part of multimodal)
  • *used IV as a variable or constate rate infusion (CRI) for pain management in perioperative period
26
Q

May also have effects on various receptors (4)

A
  • Mu-opioid
  • Muscarinic
  • Monoaminergic
  • GABA
27
Q

Where is ketamine metabolized and excreted?

A
  • Metabolized: liver
  • Excreted: kidney
28
Q

Inhalant sparing effects of ketamine allows

A
  • Dose-dependent decreases of inhalant anesthetics PLUS reduction of side effects of inhalant anesthetics
29
Q

Positives of ketamine

A
  • Improved post operative analgesia
  • Decreased opioid requirement
  • *chronic pain management
30
Q

What type of patients would you use ketamine for?

A
  1. Chronic pain
  2. Procedures causing severe pain
  3. As an adjuvant to opioid analgesics in perioperative analgesia
    *can get BEAVIOURAL SIDE EFFECTS
31
Q

Amandatine for treatment of

A
  • Influenza virus A infection and Parkinson’s disease in humans
  • Neuropathic pain
32
Q

Amandatine is an antihyperalgesic and is used for MULTIMODAL PROTOCOLS to

A
  • Enhance effects of NSAIDs, gabapentin and opioids
  • Decrease central sensitization
33
Q

Amandatine

A
  • Good oral bioavailability
34
Q

What are some examples of Serotonin and NE reuptake inhibitors?

A
  • Tricycle antidepressants
  • Amitriptyline (3-4mg/kg q 12h)
35
Q

Tricyclic antidepressants (TCAs)

A
  • Block reuptake of serotonin and NE in CNS=increases concentration in synaptic cleft=enhance descending INHIBITION of nociception
  • Antagonize VG Na channels
  • NMDA antagonist
36
Q

TCA analgesic effects

A
  • Occur more quickly and at LOWER doses than antidepressant effects
  • *no clinical trials in vet med
37
Q

What are the side effects of TCA?

A
  • Sedation
  • Excitability
  • Vomiting
  • Arrhythmias
  • Increased appetite
  • Weight gain
38
Q

Acetaminophen (paracetamol)

A
  • Analgesic and antipyretic effects, but WEAK anti-inflammatory activity
  • *mechanism for analgesia is poorly understood
  • *contraindicated in cats (hepatotoxicity or methmoglobinemia)
39
Q

Antipyretic effects of acetaminophen are mediated by

A
  • COX inhibition
40
Q

Tetrahydrocannabinol (THC)

A
  • Major psychoactive cannabinoid
41
Q

Cannabidiol (CBD)

A
  • Primary Non-psychoactive cannabinoid
42
Q

Endocannabinoid system: receptors and ligands

A
  • CB1 receptor
  • CB2 receptor
  • Endogenous ligands (endocannabinoids)
    o Anandamide (AEA)
    o 2-arachindonoyl glycerol (2-AG)
43
Q

Endocannabinoid system: lipid signaling modulates

A
  • *broad range of physiological processes and behaviours
    o Pain
    o Mood
    o Appetite
    o Emesis
    o Neuronal activity
    o Memory
    o Immunity
44
Q

CBD products

A
  • Hemp based product
  • *no quality control
    o 60 different active compounds in cannabinoids
    o THC must be less than 0.3%
    o Contamination!
  • *used for anxiety, seizures, anorexia, vomiting, pain and sleep aid
45
Q

CBD for canine osteoarthritis

A
  • CBD oil for 4 weeks
  • Owners blinded
  • *decreased pain and increased activity
  • *increased liver enzymes (alkaline phosphatase)
46
Q

Current reality of CBD products

A
  • Lots of uncertainties
  • *need more scientific evidence
47
Q

Nerve growth factor (NGF)

A

-Inflammatory mediator produced by tissue damage of osteoarthritis
- *interaction with tropomyosin kinase A receptor (TrkA)
- Key regulator in inflammatory and neuropathic pain

48
Q

NGF is a key regulator in inflammatory and neuropathic pain: ‘mechanism’

A
  • Elicits release of other inflammatory mediators
  • Increases nerves sensitivity
  • Causes phenotypic (physical and biochemical) changes in nerve
49
Q

What are the phenotypic changes that NGF does to the nerve?

A
  • Increased pain receptors, proinflammatory mediators and ion channels are produced
  • Neurogenic inflammation (key component of osteoarthritis pain)
50
Q

Anti-nerve growth factor monoclonal antibodies

A
  • Free NGF can be captured
    o Lower NGF available to bind to nociceptors
    o Help normalized changes to nerve seen with chronic pain
    o Reduce nerve sensitivity and alleviate OA pain
51
Q

mAbs in general and anti-NGF mAbs

A
  • Species-specific
  • *very specific actions
  • No significant adverse effects
  • Single SC infection=potential pain relief for 4 weeks of pain relief
    o May need see positive effects until 2 months (so be patient)
  • *non-narcotic, non-sedating
52
Q

Solensia in cats

A
  • Anti-NGF mAb
  • Can sting when injected!

ANESTHESIA (27 decks)

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