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Pharm Unit 8 > Analgesia > Flashcards

Analgesia Flashcards

1
Q

principles of pain therapy (pre-opioid crisis)

A

give scheduled
verify effectiveness
allow for dose titration
not “1-2 tabs” without indicating when to use 2 vs 1

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2
Q

for severe pain, provide ___

A

long acting analgesics ATC

short acting analgesics PRN for break through pain

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3
Q

non-opioids

A

NSAIDs

Acetaminophen

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4
Q

adjuvant therapy

A

anticonvulsants (gabapentin)
TCAs
SSRI
SNRI

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5
Q

opiates

A

codeine

morphine

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6
Q

opioids

A 
propxyphene
tramaodl
hydromorphone
oxycodone
fentanyl
meperidine
methadone
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7
Q

MOA of NSAIDs

A

inhibition of cylooxygenase (COX)

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8
Q

most NSAIDs are ___

A

nonselective for COX1 and COX2

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9
Q

COX1 is ___

A

cyto-protective

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10
Q

COX 2 is ___

A

inflammatory

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11
Q

use NSAIDs for ____ pain

A

mild-moderate

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12
Q

ceiling effects

A

additional drug gives no additional analgesia; only increases SE (NSAIDs)

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13
Q

class side effects

A

GI upset
GI irritation/ulceratio
edema
renal impairment

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14
Q

after one class of drug fails, ___

A

try another

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15
Q

Dual MOA work in ___

A

synergy

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16
Q

With combo NSAIDs, efficacy > ___

A

sum of the individual components

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17
Q

In NSAID combos, dose titration is often limited by ___

A

non-opioid

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18
Q

NSAID combos being limited by non-opioid is often the cause of ___

A

unintended overdose

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19
Q

most hepatic failures with NSAIDs are from ___

A

excessive opioid/APAP use

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20
Q

usual max of acetaminophen

A

4g/d (soon to be 3g/d per FDA)

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21
Q

usual max for Aspirin

A

4g/d (higher for anti-inflammatory)

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22
Q

usual max for ibuprofen

A

3.2g/d

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23
Q

salicylic acids (aspirin) is a ___

A

weak anti-inflammatory agent

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24
Q

aspirin is contraindicated if ___

A

<16 years (risk of Reye’s Syndrome0

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25
Q

low dose aspirin

A

81mg

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26
Q

anti-inflammatory dose of aspirin

A

3.6-5.4 g/d

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27
Q

propionic acids (ibuprofen) are ___

A

anti-inflammatory, antipyretic, analgesic

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28
Q

max inflammatory dose of ibuprofen

A

3.2g/d

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29
Q

max pain/fever/dysnemorrhea dose of ibuprofen

A

1.2 g/d

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30
Q

only commonly injectable NSAID

A

ketorolac (toradol)

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31
Q

ketorolac is used for ___

A

mod-severe pain

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32
Q

NSAID useful for post-op pain

A

ketorolac

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33
Q

ketorolac is only used for___

A

5 days due to increased risk of GI bleed

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34
Q

ketorolac usual dose

A

30mg IVP q6

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35
Q

max dose of ketoroalc

A

120mg/d

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36
Q

dise reduction of ketorolac:

A

patients >65
body weight <50 kg
“moderately elevated” serum creatinine

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37
Q

mefenamic acid is used for ___

A

mild-mod pain

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38
Q

avoid ___ when using mefenamic acid

A

alcohol (enhances mucosal irritation)

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39
Q

this NSAID is little used

A

mefenamic acid

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40
Q

NSAIDs mainly used for acute and chronic RA and OA

A

piroxicam

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41
Q

advantage of piroxicam is

A

long half life

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42
Q

piroxicam allows for ___

A

daily dosing

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43
Q

reduce dose of piroxicam with ___

A

hepatic dysfunction

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44
Q

only remaining selective COX2 inhibitor

A

celecoxib

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45
Q

Rofecoxib increased number of ___

A

cardiac events (AMIS)

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46
Q

CoX2 inhibitors are very useful in

A

non-cardiac patients (orthopedics)

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47
Q

Acetaminophen is an effective ___

A

analgesic, antipyretic

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48
Q

APAP has little ___

A

anti-inflammatory activity

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49
Q

many ____ following overdose on APAP

A

hepatic failures

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50
Q

recommended max dose of APAP

A

4g/d (3g/d soon?)

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51
Q

avoid APAP in patients with ___

A

alcoholic liver disease

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52
Q

MOA Of APAP

A

inhibits both COX isozymes

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53
Q

COX inhibition may be more pronounced in the ___

A

brain

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54
Q

APAP inhibits ____

A

hypothalamic heat-regulating center

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55
Q

when adjusting APAP for renal impairment, ___

A

metabolites accumulate

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56
Q

CrCl 10-50 give APAP ___

A

q6h

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57
Q

CrCL <10 give APAP ___

A

q8h

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58
Q

infant drop dose of APAP

A

100mg/mL

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59
Q

injection dose of APAP

A

Afirmed: 1000mg/100mL (post op x 4 doses, $$$)

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60
Q

dose of injection APAP adults / adolescents >50kg

A

1000mg q6h

MAX 4G/D

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61
Q

Injection (Afirmed) adults adolescents <50 kg dose

A

15mg/kg q6 OR 5mg/kg Q4

MAX 75 mg/kg/d

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62
Q

child dosing for APAP

A

10-15mg/kg/d

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63
Q

APAP toxicity tx

A

oral therapy: Mac (Mucomyst)

IV therapy: (Acetadote)

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64
Q

long term acetaminophen use during pregnancy resulted in ___

A

2 fold increased risk of offspring having ADHD

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65
Q

APAP used for <8d during pregnancy was assc w/ ___

A

decreased risk in ADHD

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66
Q

remeasured pain score 2 hr post dose most reduction to least reduction

A

oxycodone
hydrocodone
codeine

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67
Q

MOA of Opioid receptors

A

mu-classical analgesic receptor

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68
Q

opioid receptors are the basis of ___

A

mixed agonist-antagonist agents

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69
Q

opiates = ___

A

natural agents from opium (codeine, morphine)

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70
Q

opioids = ___

A

modifications of natural opiates (synthetics)

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71
Q

mixed opioid agonists-antagonists

A

buprenorphine
butorphanol
pentazocine
nalbuphine

72
Q

mixed agents are __

A

little used

73
Q

exception ot mixed opioid agonists not being used is __

A

nalbuphine

74
Q

nalbuphine is more effective in ___

A

females

75
Q

nalbuphine has a ceiling effect on ___

A

respiratory depression

76
Q

napbuphine is used in ___

A

labor/delivery

77
Q

endorphins are derived from __

A

small endogenous peptide hormones

78
Q

endorphins account for ___

A

variability of response to pain

79
Q

opiate/opioid side/adverse effects

A 
nausea
itching
sedation/cognitive impairment
respiratory depression
meiosis
decreased GI peristalsis
80
Q

tolerance does not develop to

A

opioid AEs

81
Q

opioids for mild-moderate pain

A

tramadol
codeine
hydrocodone

82
Q

tramadol is a ___

A

weak opioid analgesic – useful for chronic pain

83
Q

ultram is ___

A

immediate release

84
Q

ultracet is __

A

tramadol 37.5mg/acetaminophen 325mg

85
Q

ultram

A

ER tabs

86
Q

increase dosage of tramadol over ___

A

weeks – high incidence of N/V (limits usefulness for acute pain)

87
Q

tarmadol has a ___ MOA

A

dual

88
Q

tramadol is useful for __

A

neuropathic pain

89
Q

tramadol is now a ___

A

controlled substance

2014–CIII

90
Q

codeine is a ___

A

weak alagesic, antitussive

91
Q

60mg codeine produces less analgesia than ___

A

aspirin 650mg

92
Q

codeine is metabolized by __

A

CYP2D6 to morphine

93
Q

cyp2d6 inhibitors ___

A

decrease codeine’s effect

94
Q

antiemetic phenothaizenes

A

thorazine, compazine, phenergan)

95
Q

cyp2d6 inhibitors

A

haloperidol, fluoxetine, paroxetine

96
Q

10% of the population lack the ___ enzyme

A

cyp2d6

97
Q

codeine is available alone or in combination w/

A

acetaminophen

98
Q

hydrocodone is only available ___ w/ ___

A

PO with acetaminophen

99
Q

Norco dose of acetaminophen

A

325mg

100
Q

hydrocodone:

A

norco
lortab
vicoden

101
Q

hydrocodone allows better ___

A

pain relief and longer duration than codeine

102
Q

hydrocodone is metabolized by __

A

cyp2d6 to hydromorphone (dilaudid)

103
Q

63% of unintentional overdoses involve combination products, most commonly ___

A

hydrocodone

104
Q

opioids for moderate to severe pain

A 
morphine
hydromorphone
oxycodone
meperidine
methadone
fentanyl
105
Q

morphine prototype pure ___

A

mu receptor agonist

106
Q

morphine has 2 active metabolites, both __ eliminated

A

renally

107
Q

morphine-3-glucuronide is a ___

A

neurotoxin

108
Q

morphine-6-glucuronide provides ___

A

analgesia 2-4x that of morphine

109
Q

morphine induces ___

A

histamine release (hypotension, pruritus)

110
Q

morphine has a significant _____

A

first-pass effect

111
Q

morphine has a parenteral-to-oral dose ratio of:

A

1:3

112
Q

dose of morphine sulfate injection

A

2mg/mL

113
Q

dosage forms of morphine sulfate

A 
injection
immediate release tabs
SR capsules (Kadian) 
CR tabs (MS Contin) 
Oral solution (Roxanol)
114
Q

5-7x more potent than morphin

A

hydromorphone (dilaudid)

115
Q

hydromorphone (dilaudid) often results in ___

A

iatrogenic overdoses

116
Q

hydromorphone’s imported SE profile:

A

less histamine erelease

no active opioid metabolites

117
Q

sustained released form of hydromorphone

A

exalgo

8, 12, 16, 32 mg CR tabs

118
Q

alcohol destroyed time-release mechanism of SR Palladone causing –

A

overdoses

119
Q

dose of injectable dilaudid

A

2mg/mL

120
Q

oxycodone is more potent w/ fewer side effects than ___

A

morphine

121
Q

oxycodone is metabolized by ___

A

cyp2d6 to oxymorphone (also active)

122
Q

oxycodone is useful in patients with ___

A

cyp2d6 deficiency or on inhibitors

123
Q

oxycodone is useful in nonresponders to ___

A

non-responders to codeine and hydrocodone

124
Q

dosage forms of oxycodone

A 
oxycodone IR
roxicodone
oxycodone CR 
with acetaminophen 
with aspirin
125
Q

meperidine is not recommended as ___

A

1st line agent

126
Q

meperidine is ___ causing more rapid onset, shorter duration (2-3h)

A

lipophilic

127
Q

meperidine is metabolized to active metabolite ___

A

normeperidine (neurotoxic)

128
Q

meperidine has long ___

A

metabolite half life

129
Q

meperidine causes

A

euphoria, irritability, seizures

130
Q

toxicity of meperidine is not reversed by ____

A

opiate antagonists

131
Q

meperidine metabolites is __ eliminated

A

renally

132
Q

meperidine is contraindicated in patients on ___

A

MAOIs (serotonin syndrome)

133
Q

meperidine may be used in patients with serious ___

A

opiate allergies

134
Q

meperidine is useful in controlling ___

A

post anesthesia shivering

135
Q

methadone has unique pharacology:

A

racemic mix of I and D isomers.

136
Q

I isomer of methadone –>

A

opioid activity

137
Q

d isomer of methadone –>

A

NMDA antagonist & NE/5HT reuptake inhibitor

138
Q

methadone is useful for __

A

neuropathic pain

139
Q

methadone has the longest half life :

A

12-190h; usually ~24h

140
Q

methadone is useful in treatment of

A

opiate addiction (dosed q24h)

141
Q

analgesia from methadone only lasts ___

A

4-8h

142
Q

dose methadone q___ for analgesia

A

6-8h

143
Q

fentanyl is __x more potent than morphine and is dosed in __

A

100x; mcg

144
Q

fentanyl is extremely ___

A

lipophilic.

145
Q

fentanyl has __ onset and __ duration

A

rapid onset; short duration (30-60 minutes)

146
Q

___ has many fewer adverse reactions than morphine or dilaudid

A

fentanyl

147
Q

fentanyl has minimum ___

A

histamine release, hypotensive effect

148
Q

dosage forms of fentanyl

A

injection
lozenge
transdermal

149
Q

duragesic cautions are not usually used in ___

A

opiate naive pateints

150
Q

monitor respiratory rate using duragesic cautions for ___

A

24h

151
Q

replace duragesic cautions q __h

A

72h

152
Q

look for multiple patches when ___

A

discharging patients (don’t just continue adding additional patches.)

153
Q

fentanyl is only used for ___

A

standing chronic (cancer) pain

154
Q

naloxone is a pure ___

A

mu receptor antagonist

155
Q

naloxone is used to reverse ____

A

sedation/respiratory depression but ALSO REVERSES ANALGESIA

156
Q

administration of naloxone

A

dilute 0.4mg to >10mL saline
administer via SLOW IVP (1mL/1-2m)
monitor respiratory rate
stop when respiratory rate increasess

157
Q

____ is used to establish useful analgesic regimens

A

equianalgesisc dosing

158
Q

nonpharmalogic therapy and nonopijoid pharmacologic therapy are perferred for ___

A

chronic pain

159
Q

when staring opioids for chronic pain, clinicians should ___

A

prescribe immediate release opioids instead of ER/long-acting

160
Q

when prescribing opioids for acute pain, use ___

A

the lowest effective dose of IR opioids for 3-7d

161
Q

evaluate benefits and harms within ___ of starting opioids for chronic pain and again every ___

A

1-4 wks

every 3 mo or more frequently

162
Q

incorporate strategies to mitigate risk of opioid addiction such as:

A

naloxone

163
Q

monitor a patient’s ____

A

controlled substance use

164
Q

use drug urine drug screening before starting ____

A

opioid therapy and at least annually.

165
Q

avoid prescribing opioids and ___ concurrently

A

benzodiazepines

166
Q

offer or arrange evidence based treatment for patients with ___

A

opioid-use disorder (OUD)

167
Q

buprenorphine is a partial ___

A

opioid agaonist

168
Q

buprenorphine helps relieve ___

A

withdrawal sx

169
Q

buprenorphine may begin with __

A

opioids in the patient’s system

170
Q

naltrexone is an ___

A

opioid antagonist

171
Q

naltrexone may precipitate ___

A

withdrawal symptoms

172
Q

naltrexone is only available in ___ and ___

A

PO daily and IM monthly

173
Q

must be opioid free to start __

A

naltrexone

174
Q

methadone is ___

A

log-acting opioid agonsit

175
Q

methadone transfers opioid addiction to longer ___

A

half-life agonist, allowing taper

176
Q

methadone requires ___

A

daily PO dosing

Pharm Unit 8 (3 decks)

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