adjuvant analgesia

Question 1

Bone pain description

Answer 1

• Progressive worsening, achy pain, worse with weight bearing and at night
• tender over bone
• joint pain

Question 2

alternative to meds for bone pain

Answer 2

radiation especially if pain is better with steroids

Question 3

Drug classes for adjuvant bone pain

Answer 3

• NSAIDS
• Bisphosphonates
• Steroids

Question 4

Bone Pain NSAIDS

Answer 4

• Diclofenac 1.3% patch BID
• Ibuprofen 400-800mg PO q6h
• Ketorolac 30mg PO/SC/IV q6h

Question 5

bisphosphonates in bone pain

Answer 5

• pamidronate 60-90mg in 500-1000ml of NS IV over 4-6h
• Zoledronic Acid 4mg IV q4wk

Question 6

Steroids in bone pain

Answer 6

dexamethasone 2-10mg po/sc qd

Question 7

Visceral pain description

Answer 7

Colicky, cramping, abdominal pain or bladder spasms

Question 8

Visceral pain alternatives to medications

Answer 8

Paracentesis for ascites, nerve blocks, opioids are generally less effective

Question 9

Visceral pain medication classes for adjuvants

Answer 9

• Anticholinergics
• steroids
• benzodiazepines
• prokinetic
• antisecretory agent

Question 10

Anticholinergics for visceral pain

Answer 10

• glycopyttolate 0.4mg po/sc q4hr
• B&O suppositry max 4/day
• scopolamine 1-2TD patch q3 day
• hyoscyamine 0.125mg PO/SL q4-8hr
• Oxybutynin 5-10mg po q8hr

Question 11

Steroids for visceral pain

Answer 11

dexamethasone 2-10mg po/sc qd-BID

Question 12

Benzos for visceral pain

Answer 12

Lorazepam 0.5-1mg PO/SC q4-8h

Question 13

Prokinetic agents for visceral pain

Answer 13

metoclopramide 5-10mg PO/SC q4hr

Question 14

Antisecretory agent for visceral pain

Answer 14

octreotide 100mg SC/IV q8hr

Question 15

Neuropathic pain description

Answer 15

continuous burning, tingling, pain on light touch, shooting or stabbing pain

Question 16

Med classes for Neuropathic pain

Answer 16

• TCA
• Antidepressants
• anticonvulsants
• Anesthetic
• SNRI
• Other

Question 17

TCA for neuropathic pain

Answer 17

• amitriptyline 10-150mg po qhs
• Imipramine 10-150mg PO qhs
• Nortriptyline 10-50mg PO qhs
• Desipramine 10-150mg PO qhs
• Doxepin 10-50mg PO qhs

Question 18

Antidepressants for neuropathic pain

Answer 18

trazadone 25-150mg PO qhs

Question 19

Anticonvulsants in neuropathic pain

Answer 19

• gabapentin 100-300mg PO q8h
• pregabalin 25-50mg PO q8hr
• Valproate 250mg PO/IV q8-12hr
• carbamazepine 200mg PO q12h (monitor)
• lamotrigine 100-200mg PO q12hr
• Topiramate 100-200mg PO q12h
• Clonazepam 0.5mg PO BID
• Phenytoin 300-400mg PO qd

Question 20

Anesthetic for neuropathic pain

Answer 20

• ketamine
• mexiletine 150mg BID-TID
• Lidocaine Sc/IV/5% TD
• Lidocaine/prilocaine (EMLA) topical

Question 21

SNRI for neuropathic pain

Answer 21

• venlafaxine XR 37.5mg PO qd
• Duloxetine 30-60mg PO qd

Question 22

Other meds for neuropathic pain

Answer 22

• Clonidine 0.1-0.3mg PO BID
• Baclofen 5-20mg PO TID
• Capsaicin 0.025 or 0.075% cream topical QID

Question 23

Ketamine

Brief in adjuvant

Answer 23

• dissociateive anesthetic with analgesic prop in subanesthetic doses
• Head/neck cancer pain
• neuropathic pain

Question 24

Ketamine receptors

Answer 24

• NMDA antagonist
• Calcium and Na channels
• noradrenergic and serotonergic reuptake inhibition
• mu, kappa, and delta like effects

Question 25

Ketamine solubility

Answer 25

Lipid and water

allows PO, PR,SC,IM, IV, intranasal, and transdermal dosing

Question 26

metabolism of ketamine

Answer 26

extensive first pass metabolismto norketamine, active metabolite with analgesic properties

Question 27

ketamine onset of action

Answer 27

IV/IM 1-5 min
SC 15-30min
PO 30min

Question 28

Half life of ketamine

Answer 28

ketamine 1-3h
Norketamine 12hr

Question 29

Duration of action of ketamine

Answer 29

IV/IM/SC 20-45min, PO 4-12hr

Question 30

PO:IV ratio of ketamine

Answer 30

1:1