28: Non-narcotic Pain Management - Frush Flashcards
what inhibits phospholipase?
corticosteroids
what inhibits COX?
NSAID
ASA
why COX2 not COX1?
COX 2 is responsible for inflammation pathways; COX1 is more physiological functions (side effects)
potential complications of NSAIDs
- GI
- CV (black box for heart conditions)
- Renal
- can exacerbate asthma symptoms (prostaglandins can act as bronchodilators)
GI risk factors with NSAID use
- Concomitant use with: ASA(Risk with both nonselective and selective);Other NSAIDs; Corticosteroids; Anticoagulants - Age >65 - Use of high doses of NSAIDs - Cardiovascular disease
does COX2 have CV risks?
- Suppresses synthesis of prostacycline leaving Thromboxane A2 production unopposed
- Excess Thromboxane A2 causes:Vasoconstriction, Platelet aggregation, Thrombosis
why do NSAIDs have renal effects?
- COX 1 maintains GFR
- COX 2 found in kidneys (Thought to play a role in medullary blood supply, Na+ balance and systemic blood pressure)
- NSAIDs and COX 2 inhibitors (Shown to increase fluid retention; Increase blood pressure; Can exacerbate CHF)
how do you make an NSAID safer for GI issues?
add a PPI
what do NSAIDs do to the following drugs? B blockers ACE i diuretics lithium methotrexate
May decrease effect of
- B blockers
- ACE inhibitors
- Diuretics
May increase levels of
- Lithium
- Methotrexate
use with cyclosporine can cause nephrotoxicity
warfarin and NSAID?
synergistic - can cause increased bleeding
most CV neutral of NSAIDs
naproxen (aleve)
- but can affect BP
used for acute gout attacks
indomethacin (has high GI side effects)
NSAID that only needs to be taken 1x daily
meloxicam
only COX2 selective inhibitor available
celebrex
sulfa allergy warning
how do corticosteroids work?
- Help reduce pain and inflammation by inhibiting arachidonic acid production
- Thus prevents production of leukotrienes and prostaglandins
- Aids in acute and chronic inflammation associated with pain and also helps with asthma
why do you need to tape people off corticosteroids?
If on cortisol chronically physiologic production of cortisol can be decreased through HPA axis
indications for steroid injections?
Intra-articular
- Osteoarthritis
- Traumatic arthritis
- Capsulitis
- Sinus tarsitis
Nonartiuclar Tendonitis - *DO NOT INJECT AROUND ACHILLES* (doesn't have sheath) - Plantar fasciitis - Neuromas or nerve entrapments - Ganglion cysts
phosphates v. acetate steroid injections
Phosphates
- Water soluble
- Clear
- Short acting
Acetates
- Water insoluble
- Cloudy
- Longer acting
- Can crystallize
- Should not use in joint injections
why is amitriptyline an increased fall risk?
- can cause orthostatic hypotension
- its a TCA
why shouldn’t you use ASA with children?
potential Reye’s syndrome
MOA ASA
inhibits platelets
when do you need supplementation with steroids?
if on 5mg or less no supplementation
for most podiatric procedures, sufficient to give 25mg prior to start of procedure on top of regular dose
contraindications to steroid injections
absolute: joint sepsis, prosthesis, fracture, bacteremia
relative: joint instability, coagulapthy, celluites, greater than 3-4 injections to area in past year
what are the steroid injections most commonly used in podiatry?
- dexamethasone ( 4-16 mg/mL)
- triamcinolone (10 or 40 mg/mL)
- beamehtasone ( 3 mg/mL)
steroid injections should be mixed with lcoal anesthetic to give immediate relief and reduce injection discomfot
1-2 mL of LA with 0.5-1 mL of steroid
what is the dosage and use for acetaminophen?
- no anti-inflammatmory properties
- good fever reducer
- 325-1000 mg po every 4-6 hrs
- max dose 4 grams
what drugs can you give for neuropathy pain?
- amitriptyline/elavil (TCA)
- gabapentin/neurontin (antivonvulsant)
- pregabalin/lyrica (anticonvulsant)
- duloxetine/cymbalta (SSNRI)
- tapentadol/nucynta (opioid)
NSAID contraindicated in pregnancy
diclofenac
sulfa allergy
caution with celebrex
side effects/complications of corticosteroids
- weight gain
- increased blood glucose levels in diabetes
- osteoporosis
- immunosupression
- decreased wound healing
- tendon rupture
