6B. Analgesics Flashcards
Pre-emptive Ibuprofen
Placebo Placebo Ibuprofen 400 mg Time to medication: \_\_\_\_ Ibuprofen 400 mg Time to medication: \_\_\_\_
• if you give 400 mg 1 hour prior to surgery (won’t cause big anti-PLT action or see any increase in intra-operative bleeding) - the average time until they needed pain meds was much longer
◦ SO you need to: 1) pre-emptive ____ + 2) dose ____ the clock for first 8 hours to prevent pain breakthrough
236
241
dose
around
• This drug is sort of like “John Kasik”, the governor of Ohio (wth hersch?) - 83% approval rating of Democrats AND Republicans…..crickets
• Combunox - “combined w/ ____”
◦ never gained any traction for some reason (kinda like that governor joke)
◦ bee-tee-dubs: look at the oxycodone results, thing is barely better than a ____ pill! again cuz pain is driven by PGEs +
____
◦ Can see advantage of adding opioid is early on with slightly higher ____ effect, but after 3 hours it’s about the same
◦ this drug was too expensive
oxycodone
sugar
inflammation
maxium
• post-marketing dental impaction study:
◦ Lortab - no longer used cuz too much ____
‣ has ____
◦ Combunox + Percocet have same levels of ____
‣ herschy isn’t surprised the combunox did so well cuz it has much higher levels of ibuprofen than the others
• *Remember that these are average curves of like 63 people. Doesn’t mean that it works for everyone! it’s average!
◦ this where personalized medicine is coming in which is where I’m going w/ some of my research
acetaminophen
hydrocodone
oxycodone
• what is Naproxen? it’s 2 ____! haha OTC drug!
◦ when using naproxen, use the ____ salt form cuz it dissolves faster in the stomach
‣ OK I think he’s tryna say the Sodium Salt OTC form is Aleve
‣ the Rx formula = ____
◦ Naproxen has a longer 1⁄2 life than ____
‣ what’s the trade-off though? not as kind to the stomach. So you’ll see more ____
‣ but you’ll have better compliance cuz they don’t have to take it as much
◦ In older people, MRD for Aleve is ____ pills - drug might accumulate as kidney function goes down
‣ of course, NSAIDs toxicity effects are primarily on GI + kidney
◦ Risk factor for GI ulcers? Being over ____.
‣ In people w/ ____ that are prescribed Naproxen over months/years (880-1100mg/day) the incidence of GI bleeds/ulcers is about 3%/year (how in the hell does he pull these numbers out of his arse like that????)
• You would think that these side effects would prevent them from being on the market, but for people that can’t move due to arthritis, you take the risk
‣ As dentists, we don’t really get into this problem b.c we’re prescribing it short term. (so why are we learning this? - the meta question of D1/D2)
• BUT, as dentists, if you see someone w/ the ____ in the 40s, you’re not prescribing this. Or if they have a Hx of ____ bleeding
• **remember, these drugs can impair ____ excretion in kidneys!! -> putting them on NSAIDs can morph them from poor renal fx to acute renal failure
aleves sodium anaprox ibuprofen heartburn 2
65 RA GFR GI Na/H2O
• Gonna have patients that don’t want OTC drugs b.c they believe since they’re OTC they’re not as powerful
• so for these, you write for NSAIDs they don’t know about like ____ or Diclofenac (most widely prescribed in the
world)
◦ when you take Diclofenac chronically, 3-4% of ppl have rises in ____ enzymes so that’s why it’s prescribed
◦ FDA approved 25 mg dose for the liquid capsule form
◦ tablet form: you do NOT want to prescribe the “____” form or the K+ form
‣ Max dose is ____mg
‣ but for liquid capsule Zipsor, it’s only ____mg
meclofenilate liver volterin 150 100
Toradol and Toradol
• sounds like Diclofenac and it’s similar
• if you were to have a ____, you’d prolly get an IM injection of this - v good for this type of pain
◦ 3 forms: IM or IV, oral, ____ (nose has good blood supply so gets right into blood supply)
kidney stone
intranasal
Toradol vs. Morphine in postop pain
• Laminectomy (back surgery - fusing vertebrae), hysterectomy, etc
◦ these surgeries have a large inflammation response so prolly why the NSAIDs work so well
• 10-30 mg of this stuff was as good 12 mg IM ____
morphine
Toradol vs. Acetaminophne pluse codeine, aspirin and placebo in dental postop pain
• Blue line = Aspirin ____ dosages
• Yellow = Tylenol 3 ____ doses
• and then you have 10 mg of oral ____ doing better than them all
◦ what’s weird about the dosing here? the oral dose is normally a fair amount more than IM, but here it’s less…
◦ reason: nastiest NSAID on ____
2
2
toradol
GI tract
DOSAGE AND ADMINISTRATION
Ketorolac Tromethamine Tablets
• Ketorolac tromethamine tablets are indicated only as continuation therapy to ketorolac tromethamine injection, and the combined duration of use of ketorolac tromethamine injection and ketorolac tromethamine tablets is not to exceed ____ (five) days, because of the increased risk of serious adverse events.
• “so you should know this here:” black box warning
• do not use me fore more than 5 days; don’t use oral dose unless person has started ____ dose (transition them from injectable
to oral once outpatient)
◦ the MAX is 5 days combined!
5
injectable
Relationship bt Pain and PGE2 levels at the site of injury
• Injectable Toradol
◦ look at the pain intensity vs placebo - huge difference
• Look at graph on right: measuring PGEs in extraction socket ◦ shows how and why drug is working
yay
• Paracetamol 1000- acetaminophen (2 Extra Strength Tylenol)
◦ effects just as good as ibuprofen 400 - hersch doesn’t like this
• What beats them both? 200 ____ + 500 ____
◦ if taking every 4 hours, you still keep acetaminophen dose @ ____g. Drug packaging says 3.
• Overall winner!: 400 ____ + 1000 ____
◦ what hersch doesn’t like: these are average curves so there’s some people buried in there where it hardly worked and if they keep
dosing with that amount, they’re going to end up w/ a super dose of acetaminophen
◦ so what do they recommend? 400 ____ + 500 ____ - hasn’t been well studied, but they’re going to do it in a study
soon
ibuprofen acetaminophen 3 ibuprofen acetaminophen
ibuprofen
acetaminophen
• another study w/ Ibuprofen acetaminophen (APAP is chemical name)
◦ combo here is working just as well as 2x ibuprofen
◦ much more “Staying power” than 1000 APAP w/ codeine 30
◦ ____ effect: ibuprofen + APAP and no one is getting addicted to it
‣ he still thinks about 1⁄4 of patients will still require a vicodin or two every 4-6 hours
‣ this ties into the personal medicine he talked about earlier
additive
ADVANTAGES OF NSAIDs FOR ACUTE PAIN • Relief equivalent to \_\_\_\_ combos • Minimum of \_\_\_\_ side effects • Generally favorable \_\_\_\_ • Several \_\_\_\_ classes
narcotic
CNS
therapeutic index
chemical
Role of prostaglandins
• PGEs involved in pain, menstrual ____, inflammation, fever
• all NSAIDs, acetaminophen, etc are anti-pyretic: reduce ____. Why is this bad? b.c fever is early sign of post-op ____ so you can’t
see it when patients taking these
• effect in Kidneys: increase ____, increase H2O/Na excretion
• Aspirin + Ketorolac have the highest ____ activity
cramps fever infection blood flow anti-platelet
LIMITATIONS OF NSAID ANALGESICS • Plateau of \_\_\_\_ effect • Gastrointestinal upset/toxicity • Inhibition of \_\_\_\_ • Tinnitus • Specific contraindications – \_\_\_\_ – Aspirin/NSAID sensitive asthma – Aspirin/NSAID \_\_\_\_ – Lithium or anticoagulant intake (warfarin, Eliquis®) – \_\_\_\_ (Aspirin)
if any of these contraindications are present, you give ____ or the combo of ____ w/ ____
analgesic platelets ulcers allergy reyes syndrome
acetaminophen
APAP
opioid
