Acute Pain Flashcards
APAP
- Tylenol, Ofirmev
- Max Dose: 4g from all sources
- Boxed Warnings: Severe hepatotoxicity (>4g)
- SE: severe skin rash (Rare)
- Ethanol use: consuming >= 3 drinks per day can increase liver damage risk
- Hepatic impairment: use with caution if patient has impairment of acute liver disease
APAP + Geriatrics
-Some recommend a max dose of 3g per day
Mild Pain Options
- APAP
- COXIBs
- NSAIDs
- Local/regional anesthesia
Moderate Pain Options
-Low dose opioids \+ -APAP -COXIBs -NSAIDs -Local or regional anesthesia
Severe Pain Options
-Higher dose of opioids \+ -Low doses of opioids \+ -APAP -COXIBs -NSAIDs -Local or regional anesthesia
Chronic Liver Disease/Cirrhosis + APAP
- Use with caution and consider dose adjustment
- Limited data exists, but =<2 or 3g/day is usually well tolerated in these patients
- Patients not actively drinking alcohol
NSAIDs + Kidneys
- Coadministration with certain drugs increase kidney injury risk
- Includes ACE-I, ARBs, antirheumatics (Methotrexate), Diuretics, and Lithium
NSAIDs + CV Risk
- Risk of adverse CV effects
- Consider baseline ASCVD risk
- High NSAID doses are associated with higher CV risk
- COX-2 selective agents don’t seem to have a significant CV risk factor
COX-2 Selective NSAIDs
- Lower risk for complications
- Increased risk of MI/stroke
- Same risk for renal complications
Bleed Risk + NSAIDs
- Coadministration of certain drugs increase bleed risk
- Includes anticoagulants, antiplatelets, corticosteroids, SSRI, SNRI, TCA, and herbals
Ketorlac
- Toradol
- Pain management (acute, moderately severe) in patients >= 50 kg
Multimodal Analgesia
- APAP
- Gabapentin/pregabalin
- Ketamine
- NSAIDs
- Skeletal muscle relaxants
- Steroids
Methocarbamol Warnings/SE
- Considerations: half-life is prolonged in older adults and has increased risk of drowsiness/dizziness (Beers List)
- Warning: caution with other CNS depressants (increased CNS depression)
- SE: dizziness, drowsiness, HA, insomnia, metallic taste, N/V
Antispasmodic Agents
- Cyclobenzaprine
- Metaxalone
- Methocarbamol
Antispasticity Agents
- Baclofen
- Dantrolene
Antispasmodic/Antispasticity Agents
- Diazepam
- Tizanidine
Beers List + Antispasmodics
- Atropine
- Belladonna
- Dicyclomine Hometropine
- Hyocyamine
- Scopolamine
Beers List + Skeletal Muscle Relaxants
- Carisoprodol
- Cyclobenzaprine
- Metaxalone
- Methocarbamol
OIC Management Options
-Traditional Laxatives: Osmotic, Stimulant, Detergent/surfactant, lubricant
PAMORAs
Traditional Laxatives
- Strong recommendation for OIC
- Moderate leveled evidence
- First-line Agent
PAMORAs
- Peripherally acting mu opioid receptor antagonists
- Generally recommended for laxative refractory OIC over no treatment
- Depending on medication, recommendation is strong or conditional
- Level of evidence ranges from high to low depending on the situation
Type A ADR
- Predictable, dose-dependent effect
- From known pharmacologic properties
Type B ADR
- Not dose-dependent and are unrelated to pharmacologic action of drug
- Can be patient-specific factors
- EX: allergies, pseudoallergic reactions, drug intolerances
Morphine Induced Itching
- From histamine release by mast cells
- Fentanyl and oxymorphone are less likely to product histamine release (still associated with pruritis)
Fentanyl Warnings/SE
- Note: Don’t use in opioid naive
- Warning: potential for dosing error when converting between dosage forms, CYP3A4 inhibitors can increase its SE
- SE: Bradycardia, confusion, dizziness, diaphoresis, dehydration, dry mouth, N/V
