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NAPLEX 2024 > 58. Pain > Flashcards

58. Pain Flashcards

1
Q

Acetaminophen effects

A

Reduces pain and fever
does NOT provide anti-inflammatory effects

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2
Q

MOA for acetaminophen is not well defined but is thought to involve ____

A

inhibition of PG synthesis in the CNS

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3
Q

acetaminophen rectal suppository brand name

A

FeverAll

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4
Q

acetaminophen IV injection brand name

A

Ofirmev

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5
Q

APAP/hydrocodone brand name

A

Norco

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6
Q

acetaminophen/codeine brand name

A

Tylenol #3

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7
Q

acetaminophen/caffeine brand name

A

Excedrin Tension Headache

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8
Q

acetaminophen/aspirin/caffeine brand name

A

Excedrin Extra Strength, Excedrin Migraine

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9
Q

acetaminophen/caffeine/pyrilamine brand name

A

Midol Complete

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10
Q

acetaminophen max dosing for adults

A

<4g/day

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11
Q

acetaminophen pediatric dosing (<12 yo)

A

10-15mg/kg q4-6h

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12
Q

acetaminophen infant and children’s suspension concentration

A

160mg/5mL

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13
Q

Boxed warnings for acetaminophen

A

hepatotoxicity, a/w >4g/day or use of multiple APAP-containing products

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14
Q

Antidote for acetaminophen overdose

A

N-acetylcysteine (NAC, Acetadote) - glutathione precursor (increases glutathione), administered IV or PO

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15
Q

_____ nomogram uses the serum acetaminophen level and the time since ingestion to determine whether hepatotoxicity is likely (and the need for NAC)

A

Rumack-Matthew

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16
Q

Non-aspirin NSAID boxed warnings

A

GI risk - bleeding/ulceration
CV risk - MI/stroke
Contraindicated in CABG surgery (antiplatelet therapy (commonly aspirin) is recommended after CABG surgery)

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17
Q

Aspirin MOA

A

irreversible COX-1 and 2 inhibitor

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18
Q

Side effects of all NSAIDs

A

Use cautiously or avoid in renal failure
Increased BP - avoid in uncontrolled HTN
Do NOT use in third trimester of pregnancy (can cause premature closure of ductus arteriosus)
Nausea - take with food or use EC formulation
Photosensitivity

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19
Q

What is the concern of use of NSAIDs in pregnant patients?

A

Do NOT use NSAIDs in 3rd trimester of pregnancy, NSAIDs can prematurely close ductus arteriosus

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20
Q

After birth, the ductus arteriosus should close on its own. In some cases, it remains patent (open) and ___ can be used within 14 days after birth to close it.

A

IV NSAIDs (indomethacin, ibuprofen)

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21
Q

Which non-aspirin NSAIDs are non-selective?

A

Ibuprofen (Advil, Caldolor, Motrin IB)
Indomethacin (Indocin)
Naproxen (Aleve)
Ketorolac (Toradol, Acular Sprix)

Others: piroxicam (Feldene), sulindac

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22
Q

Which non-aspirin NSAIDs have increased COX-2 selectivity?

A

CElecoxib (Celebrex)
Diclofenac (Voltaren)
Meloxicam (Mobic)

Others: Etodolac, Nabumetone

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23
Q

Ibuprofen OTC max duration of self-treatment

A

<10 days

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24
Q

Why should indomethacin (Indocin) be avoided in psych conditions?

A

High risk for CNS side effects

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25
Q

Why do prescribers and patients sometimes prefer naproxen?

A

Dosed BID (less frequent dosing)

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26
Q

Ketorolac max combined duration IV/IM and PO/nasal in adults

A

5 days

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27
Q

Ketorolac warnings

A

Acute renal failure and liver failure

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28
Q

Important notes for ketorolac nasal spray

A

Prime 5 times before use (no additional priming needed if additional doses are used, discard 24 hrs after opening)

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29
Q

Celecoxib (Celebrex) contraindications

A

Sulfonamide allergy

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30
Q

Pt has a sulfa allergy. Which NSAID should be avoided?

A

Celecoxib

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31
Q

Which non-aspirin NSAID has highest COX-2 selectivity?

A

Celecoxib

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32
Q

Diclofenac/misoprostol (Arthrotec) boxed warnings

A

Avoid in females of childbearing potential

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33
Q

____ is used to replace gut-protective prostaglandins to decrease GI risk when using diclofenac.
Note: can increase uterine contractions (which can terminate pregnancy) and causes cramping and diarrhea

A

Misoprostol

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34
Q

Cardioprotection dosing of aspirin

A

81-162 mg once daily

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35
Q

Why should aspirin be avoided in children and teenagers with any viral infection?

A

Potential risk of Reye’s syndrome

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36
Q

What brand names are the EC/buffered aspirin formulations?

A

Ascriptin, Bufferin, Ecotrin

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37
Q

Which brand names of aspirin is ER capsule and Rx only?

A

Durlaza

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38
Q

Salicylate overdose can cause ___

A

tinnitus

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39
Q

___ is a popular OTC topical found in BenGay, IcyHot, Salonpas, and Thera-Gesic

A

Methyl salicylate

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40
Q

Example of a non-acetylated salicylate

A

Magnesium salicylate (Doan’s Extra Strength)

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41
Q

Multiple NSAIDs should not be used together except the addition of low dose aspirin for cardioprotection when indicated. If using aspirin for cardioprotection and ibuprofen for pain, how should you separate doses?

A

Aspirin 1 hr before or 8 hrs after ibuprofen

42
Q

NSAIDs can increase levels of ___ and ___

A

lithium and methotrexate

43
Q

Opioids MOA

A

Mu receptor agonists (produce pain relief but also cause euphoria and respiratory depression)

44
Q

Opioids Boxed warnings

A

Addiction, abuse, misuse&raquo_space; overdose, death
Respiratory depression (can be fatal)
Concurrent use with BZD or other CNS depressants can increase risk of death
Do not consume alcohol with ER formulations, increased drug plasma levels&raquo_space; fatal overdose
Accidental ingestion/exposure in children can be fatal, never share medication (including patches)
Crushing, dissolving, or chewing ER products can cause delivery of potentially fatal dose
Avoid prolonged use in pregnancy (neonatal opioid withdrawal)

45
Q

Define physiological adaptation (physical dependence)

A

Physical withdrawal symptoms when opioid is stopped or dose is late/missed
S/sx: anxiety, tachycardia, shakiness, SOB
Note: not the same as addiction

46
Q

Side effects of opioids

A

Constipation, N/V (esp with acute, high-dose use), somnolence, dizziness/lightheadedness, risk of respiratory depression, pruritus common (esp in opioid-naive pts, can premedicate with diphenhydramine)

47
Q

Drug schedule for codeine vs codeine/acetaminophen vs oral solution combo products (cough syrups)

A

Codeine = CII
Tylenol #3, #4 = CIII
Cough syrups = CV

48
Q

Fentanyl patch dosing frequency

A

1 patch Q72H (can be Q48H)

49
Q

Which brand name of fentanyl comes in a lollipop formulation?

A

Actiq (oral transmucosal lozenge on a stick)

50
Q

Fentanyl is available in different strengths ranging from ____

A

12-100 mcg/hr

51
Q

Fentanyl is not used in opioid naive patient. What makes a pt a candidate to switch to fentanyl patches?

A

Using equivalent to morphine 60mg/day for at least 7 days

52
Q

Hydrocodone IR + acetaminophen combo products have the ___ mg of acetaminophen regardless of hydrocodone strength.

53
Q

Which opioids are CYP3A4 substrates (use with 3A4 inhibitors may cause fatal overdose)?

A

Hydrocodone, fentanyl, methadone, and oxycodone

54
Q

Hydromorphone (Dilaudid) initial opioid-naive dosing for oral and IV

A

PO: 2-4mg q4-6h PRN
IV: 0.2-1mg Q2-3h PRN

55
Q

Boxed warning for hydromorphone (Dilaudid)

A

Risk of medication error with high potency injection (use in opioid-tolerant pts only)
Note: potent opioid, higher risk for overdose

56
Q

Boxed warning for methadone

A

QT prolongation

57
Q

What is the concern of methadone dosing?

A

Variable half-life, hard to dose safely

58
Q

What is the concern of methadone use in some male pts?

A

May decrease testosterone and contribute to sexual dysfunction

59
Q

Warnings for meperidine (Demerol)

A

Renal impairment/elderly at risk for CNS toxicity - avoid with or within 2 weeks of MAOi
Increased risk of serotonin syndrome with other serotonergic drugs

Note: no longer recommended as an analgesic

60
Q

Things to note regarding normeperidine (metabolite of meperidine)

A

renally cleared and can accumulate and cause CNS toxicity including seizures

61
Q

Which brand names of morphine are injections?

A

Duramorph, infumorph

62
Q

Morphine side effects

A

Pruritus, dry mouth, hyperhidrosis
Diphenhydramine can be given to block histamine-induced pruritus

63
Q

Oxycodone IR, CR, ER brand names

A

IR = Roxicodone
CR = OxyContin
ER = Xtampza ER

64
Q

Oxycodone/acetaminophen brand name

A

Endocet, Percocet

65
Q

All oral opioids should be taken with food to lessen nausea except one. Which opioid is recommended to take on an empty stomach?

A

Oxymorphone

66
Q

Morphine, Hydromorphone, Oxycodone conversion for IV/IM and PO

A

Morphine IV/IM 10mg = Hydromorphone IV/IM 1.5mg
Morphine PO 30mg = Hydromorphone PO 7.5mg = Oxycodone PO 20mg

67
Q

T/F: opioids are typically first-line for chronic pain treatment d/t strength and efficacy

68
Q

Opioids that cross-react in opioid allergy

A

Drugs that have cod or morph (norph)
Codeine, hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, burprenorphine, heroin (diacetyl-morphine)

68
Q

Opioid-induced respiratory depression risk factors

A

Hx of previous overdose
substance use disorder
large doses (≥50mg morphine or equivalent)
Use of BZD, gabapentin, or pregabalin
Comorbid illnesses, such as respiratory or psychiatric disease

Note: Naloxone should be readily available to pts with increased risk

69
Q

T/F: constipation with opioid use is transient and will lessen over time

A

False - most opioid side effects usually lessen over time EXCEPT constipation

70
Q

What is first-line treatments for opioid-induced constipation?

A

Stimulant (e.g. senna, bisacodyl) or osmotic (e.g. PEG) laxatives with or without stool softeners
Bisacodyl comes as tablet (ppx) or suppository (treatment)

71
Q

If laxatives are not sufficient for opioid-induced constipation, what can be used?

A

Peripherally-acting mu-opioid receptor antagonists (PAMORAs)

72
Q

What are some examples of PAMORAs?

A

Methylnaltrexone (Relistor)
Naloxegol (Movantik)

73
Q

PAMORA warnings and side effects

A

GI perforation
Abdominal pain and flatulence

74
Q

Tramadol and tapentadol MOA

A

Mu-opioid receptor agonists and inhibitors of NE reuptake
Tramadol also inhibits reuptake of serotonin

75
Q

Tramadol (Ultram) drug schedule

76
Q

Tapentadol (Nucynta) drug schedule

77
Q

Warnings for centrall acting analgesics (tramadol, tapentadol)

A

Lower seizure threshold
Caution with other serotonergic drugs
Avoid tramadol with CYP2D6 inhibitors

78
Q

S/sx of opioid overdose

A

Extreme sleepiness, slow or shallow breathing, fingernails or lips turning blue/purple, extremely small “pinpoint” pupils, slow heartbeat and/or BP

79
Q

Naloxone is available in 2 options. What are they and what are the differences?

A

Narcan (nasal spray): onset is slower than injection, comes as single-use nasal pray 4mg in 1 nostril, repeat in alternating nostrils if needed
Naloxone (injection): repeat every 2-3 minutes until EMS arrives

80
Q

Side effects of naloxone or nalmefene

A

Opioid-dependent: acute withdrawal symptoms (pain, anxiety, tachypnea, diarrhea, agitation)

81
Q

Buprenorphine MOA

A

partial mu-opioid agonists
agonists at low doses and antagonist at higher doses (lower doses to treat pain, higher doses to treat addiction)

82
Q

Naloxone MOA

A

Opioid antagonists

83
Q

How does buprenorphine/naloxone combo drug work?

A

Used as alt to methadone for opioid use disorder
Buprenorphine suppresses withdrawal symptoms and naloxone helps prevent misuse

84
Q

Buprenorphine patch (Butrans) application

A

Apply to upper outer arm, upper chest, side of chest or upper back
Change weekly
Do not use same sit for at least 3 weeks
Can only be covered with Bioclusive or Tegaderm, do not exposre to heat)

85
Q

Adjuvants are commonly used in pain a/w ____

A

neuropath, postherpetic neuralgia (PHN), fibromyalgia and osteoarthritis (OA)

86
Q

____ injection can be added to opioids in intrathecal (epidural) pain infusion pumps for pts with cancer pain when other agents are insufficient

87
Q

Which gabapentin formulation is indicated for postherpetic neuralgia (PHN) and restless legs syndrome?

A

Gabapentin enacarbil (Horizant)

88
Q

Side effects of gabapentin, pregabalin

A

Dizziness, somnolence, peripheral edema/weight gain
Others: ocular effects, ataxia, nystagmus, tremor, dry mouth, mild anxiolytic

89
Q

Which adjuvant pain med for neuropathic pain is FDA-approved for treatment of trigeminal neuralgia?

A

Carbamazepine (Tegretol)

90
Q

Which adjuvant pain med for neuropathic pain is approved for use in fibromyalgia, PHN, and neuropathic pain a/w DM and spinal cord injury?

A

Pregabalin (Lyrica)

91
Q

Muscle relaxants used for pain

A

Baclofen (Lioresal)
Cyclobenzaprine (Amrix, Fexmid, Flexeril)
Tizanidine (Zanaflex)
Carisoprodol (Soma) - CIV
Methocarbamol (Robaxin)

92
Q

Poor CYP___ metabolizers will have increased carisoprodol conc, while rapid metabolizers will concert to active metabolite faster (increased tox/sedation)

93
Q

All muscle relaxant side effects

A

sedation, dizziness, confusion, asthenia (muscle weakness)

94
Q

Tizanidine (Zanaflex) side effects

A

Hypotension, dry mouth, increased LFTS

95
Q

Cyclobenzaprine (Amrix, Fexmid) side effects

A

Dry mouth
Serotonergic - do not combine with other serotonergic agents

96
Q

Lidocaine (Lidoderm) dosing

A

Apply to painful area 1-3 patches/day and wear up to 12 hrs/day
Do not apply more than 3 patches at one time
Can cut into smaller pieces (before removing backing)

97
Q

Which topical adjuvants for pain is approved for PHN (shingles) pain?

98
Q

Which medications are approved for fibromyalgia?

A

Pregabalin (Lyrica)
Duloxetine (Cymbalta)

99
Q

Which morphine product can be opened and sprinkled on apple sauce or soft food?

A

Kadian (morphine ER capsules)

NAPLEX 2024 (74 decks)

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