Analgesics and Sedative Agents Flashcards
morphine MOA
pure agonist analgesic that acts primarily on mu receptors to mimic endogenous opioid peptide actions
morphine route
PO and parenteral
morphine indications
- acute and chronic pain relief
- myocardial infarction
- pre-op sedation
- anxiety
morphine AEs
- respiratory depression and cough suppression
- constipation, emesis, and urinary retention
- sedation and increased ICP
- orthostatic hypotension
- physical dependence, euphoria, and potential for abuse
morphine nursing considerations
- tolerance, monitor for possible physical dependence and abuse
- assess and reassess pain, resp status, and GI function
- manage constipation with increased fluid and fiber intake
- monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- provide ventilatory support and admin antagonist (naloxone) for toxicity
fentanyl MOA
higher potency pure agonist opioid analgesic that acts primarily on mu receptors to mimic endogenous opioid peptide actions
fentanyl route
IM, IV, transmucosal, and nasal spray
fentanyl indications
- acute and chronic pain relief
- surgical analgesia
- off-label use of rapid sequence intubation and ICU sedation
fentanyl AEs
- resp depression and cough suppression
- constipation and emesis
- sedation and inc. ICP
- orthostatic HOTN
- physical dependence, euphoria, and potential for abuse
fentanyl nursing considerations
- transmucosal for breakthrough pain in pts w/ cancer and opioid tolerance only; monitor for possible physical dependence and abuse
- assess and reassess pain, resp status, and GI function
- more effective if admin ATC vs PRN
- monitor use with other CNS depressants, anticholinergics, antihypertensives, etc.
- admin antagonist for toxicity
codeine MOA
moderate to strong agonist opioid that acts primarily on mu receptors to mimic endogenous opioid peptide actions
codeine route
PO tab or solution
codeine indications
- mild to moderate pain
- short-term symptomatic relief of cough
codeine AEs
- similar to morphine, but slightly lesser degree
- excessive sleepiness, breathing difficulties, lethargy, and poor feeding in infants from nursing mothers on codeine
codeine nursing considerations
- same considerations as other opioids
- other formulations include those combined w/ other meds: promethazine, guaifenesin, acetaminophen, or aspirin
- assess pt’s benefits vs risks due to risk of abuse, misuse, and opioid addiction, leading to OD and death
- other common PO opioids: hydrocodone, oxycodone and their combo products
- pts lacking CYP2D6 cannot convert codeine to morphine, therefore don’t experience analgesia
tramadol (Ultram) MOA
centrally acting analgesic with pain relief achieved through weak mu agonist activity and blocking of NE and 5-HT reuptake for the treatment of moderate to severe pain
tramadol (Ultram) route
PO
tramadol (Ultram) indications
- moderate to severe pain
tramadol (Ultram) AEs
- low risk for resp. depression
- sedation, dizziness, HA, dry mouth, and constipation
- serotonin syndrome if co-admin w/ agents that enhance serotonergic transmission
tramadol (Ultram) nursing considerations
- lower abuse potential that pure agents
- utilized in suicide attempts in combo w/ other CNS depressants
- closely monitor and educate pt on use with SSRI, SNRI, tricyclic, MAOI, and triptan meds
- formulations also include combo w/ acetaminophen
methadone MOA
long-acting pure agonist that acts primarily on mu receptors to mimic endogenous opioid peptide actions
methadone route
PO, IM, and IV
methadone indications
- pain relief
- maintenance treatment of opioid use disorder
- short-term supervision of opioid withdrawal
methadone AEs
similar to morphine and fentanyl plus:
- QT prolongation
- fatal dysrhythmias (Torsades de Pointes w/ higher doses)
methadone nursing considerations
same considerations as morphine and fentanyl plus:
- establish baseline ECG, monitor heart rhythm on tele
- thorough history and assessment of opioid abuse prior to use for addiction to ensure proper methadone substitution dosing
buprenorphine/naloxone (Suboxone) MOA
agonist-antagonist opioid analgesic with both agonist and antagonist actions at mu receptors and antagonist actions at kappa receptors
buprenorphine/naloxone (Suboxone) route
buccal film, SQ/IM/IV, SL film and tab, subdermal implant, transdermal patch
buprenorphine/naloxone (Suboxone) indications
- acute and chronic pain relief
- opioid use disorder and opioid withdrawal
buprenorphine/naloxone (Suboxone) AEs
- mild resp depression
- prolonged QT interval and fatal dysrhythmias
- Sphincter of Oddi spasm
buprenorphine/naloxone (Suboxone) nursing considerations
same as morphine and fentanyl plus:
- establish baseline ECG, monitor rhythm on tele
- thorough history and assessment of opioid abuse prior to use for addiction
- monitor for GI s/s, especially in pts with biliary disease or pancreatitis
naloxone (Narcan) MOA
competitive antagonist at opioid receptors that blocks opioid actions
naloxone (Narcan) route
IV, IM, SQ, and intranasal routes
naloxone (Narcan) indications
- opioid OD
- reversal of post-op opioid effects
- reversal of neonatal resp depression
naloxone (Narcan) nursing considerations
- will not see reversal if caused by other agent
- may need repeat dose due to short half-life (0.4 mg q2-5 min. usually)
- reversal of effects include onset of pain
- other formulations help with mgmt of opioid-induced constipation and opioid addiction
ibuprofen (Advil/Caldolor) MOA
reversible non-selective cyclooxygenase inhibitor propionic acid class NSAID with inhibition of COX-1 and COX-2 (pain, inflammation, fever)
ibuprofen (Advil/Caldolor) indications
RA, OA, fever, dysmenorrhea, bursitis, and tendonitis
ibuprofen (Advil/Caldolor) AEs
- GI related effects: abd pain, N/V/D, ulcers leading to bleeding and constipation
- bleeding
- renal impairment
- inc risk for thrombotic events
- SJS (rare!)
ibuprofen (Advil/Caldolor) nursing considerations
- take w/ food, milk, or antacid
- pt education on bleeding and concurrent use with other blood thinners
- ed on using lowest possible effective dose for the shortest amt of time
- no CV protection against MI and CVA
- caution with renal impairment, monitor renal function
ketorolac (Toradol) MOA
reversible non-selective cyclooxygenase inhibitor with inhibition of COX-1 and COX-2
ketorolac (Toradol) indications
short term management of acute moderate to severe pain (post-op pts) relief similar to what is achieved with morphine
ketorolac (Toradol) AEs
- GI effects
- bleeding
- renal impairment
- inc risk for thrombotic events
- SJS (rarely)
ketorolac (Toradol) nursing considerations
- alternative for severe pain management in pts unable to take opioids
- med only used up to 5 days
- no CV protection against MI and CVA
- caution with renal impairment, monitor renal function
celecoxib (Celebrex) MOA
2nd generation selective cyclooxygenase inhibitor with inhibition of COX-2 leading to reduction in inflammation and pain
celecoxib (Celebrex) indications
OA, RA, ankylosing spondylitis, juvenile idiopathic arthritis, acute pain, and dysmenorrhea
celecoxib (Celebrex) AEs
- inc risk for MI, CVA, and other CV related events
- possible cross allergy with sulfa meds
- renal impairment (dec risk with 2nd gen)
acetaminophen (Tylenol/Ofirmev) MOA
nervous system COX inhibitor to reduce prostaglandin synthesis
acetaminophen (Tylenol/Ofirmev) indications
pain and fever
acetaminophen (Tylenol/Ofirmev) AEs
- extremely rare at therapeutic doses, including anaphylaxis, SJS, and TENS
- inc BP with daily use
- hepatotoxicity w/ excessive dosage or ETOH consumption
acetaminophen (Tylenol/Ofirmev) nursing considerations
- assess ETOH consumption
- educate on RUQ s/s, sources of acetaminophen, and safe 24-hr dosing
- acetaminophen OD in suicide attempts
- treat OD w/ acetylcysteine ASAP to prevent liver injury
sulfasalazine (Azulfidine) MOA
non biologic disease-modifying antirheumatic drug (DMARD) that uses 5-aminosalicylic acid to modulate local chemical mediators of inflammatory response, including leukotrienes
sulfasalazine (Azulfidine) indications
- mono or combo therapy for rheumatoid arthritis
- ulcerative colitis
- off-label use with psoriatric arthritis, ankylosing spondylitis, and Crohn disease
sulfasalazine (Azulfidine) AEs
- GI effects
- pruritis, rash, and uticaria
- SJS and TENS
- hepatitis and bone marrow suppression
sulfasalazine (Azulfidine) nursing considerations
- periodic monitoring for hepatitis and bone marrow function q3 months or as clinically indicated
- assess for sulfa allergy and educate on serious dermatologic side effects
- space tablets evenly throughout day, preferably after meals
etanercept (Enbrel) MOA
biologic DMARD that inhibits inflammation by neutralizing tumor necrosis factor (TNF) to prevent TNF from interacting with receptors in synovium for moderate to severe active RA
etanercept (Enbrel) indications
rheumatoid arthritis
etanercept (Enbrel) AEs
- milder AE at injection site including: erythema, itching, swelling, and pain
- opportunistic and serious infections including: bacterial sepsis, invasive fungal infections, HBV, and TB
- SJS and TENS
- HF
- lymphoma and other malignancies
- hematologic disorders
- liver injury
- CNS demyelination
etanercept (Enbrel) nursing considerations
- screen for pre-existing conditions and infections
- numerous drug interactions (particularly live vaccines)
- monitor and educate on periodic monitoring and adverse effects
- proper storage of auto-injectors, prefilled pens, and prefilled syringes in refrigerator and at room temp
rituximab (Rituxan) MOA
immunoglobulin G1 monoclonal antibody that targets CD20 proteins to deplete positive B cells via phagocytosis, cell lysis, growth arrest, and apoptosis
rituximab (Rituxan) AEs
- flu-like syndrome during initial infusion
- infusion hypersensitivity rxns (HOTN, MI, cardiogenic shock, bronchospasm, angioedema, and hypoxia)
- SJS and TENS
- HBV and JC virus reaction
rituximab (Rituxan) nursing considerations
- premedicate with IV glucocorticoid, antihistamine, and acetaminophen
- treat severe rxns w/ glucocorticoids epinephrine, and oxygen
- screen for HBV infection s/s
- monitor continuously during infusion with rates ranging from 60-400mg/hr as tolerated
abatacept (Orencia) MOA
DMARD that selectively binds with receptors on antigen-presenting cells to prevent T cell activation to reduce T-cell proliferation; reduce production of interferon gamma, interleukins, and TNF
abatacept (Orencia) AEs
- generally well-tolerated with most AE being HA, URI, nasopharyngitis, and nausea
- infusion rxns: flushing, HOTN, and dyspnea
- increased risk risk for infections including: PNS, cellulitis, bronchitis, diverticulitis, pyelonephritis, and UTI
abatacept (Orencia) nursing considerations
- live virus vaccines should not be used during treatment and for 3 months after stopping
- treatments may be periodic infusions, infusions transitioned into SQ therapy, or weekly SQ therapy only
colchicine (Colcrys) indication
anti-inflammatory agent used for acute gouty attack and prophylaxis of future gout attacks
colchicine (Colcrys) MOA
inhibits leukocyte infiltration by disrupting microtubules required for cellular motility and cell division
colchicine (Colcrys) AEs
- GI effects
- myelosuppression
- myopathy and rhabdomyolysis
colchicine (Colcrys) nursing considerations
- assess cardiac, renal, hepatic, and GI function in older adult pts
- monitor for new onset muscle pain and creatinine kinase levels
- pt education on med regimen differences
allopurinol (Zyloprim) MOA
urate lowering class agent that inhibits xanthine oxidase enzyme to decrease uric acid production
allopurinol (Zyloprim) indications
- chronic management of gout
- nephrolithiasis
- prevention of tumor lysis syndrome
allopurinol (Zyloprim) AEs
- generally well-tolerated
- GI effects
- neurologic effects (drowsiness, HA, and metallic taste)
- rare hypersensitivity syndrome
allopurinol (Zyloprim) nursing considerations
- monitor vision and educate pts on periodic examinations
- educate on place in therapy
- increase fluid intake and avoid food triggers
probenecid MOA
uricosuric class agent that acts on renal tubules to inhibit reabsorption of uric acid; helps increase excretion of uric acid by the kidneys and reduce hyperuricemia
probenecid indications
- chronic management of gout
- pharmacokinetic enhancer to prolong beta-lactam serum levels of cefoxitin or penicillin in gonoccal and neurosyphilis infections
- off-label cidofovir infusion nephrotoxicity prevention
probenecid AEs
- generally well-tolerated
- GI effects
- possible renal injury from urate deposition
probenecid nursing considerations
- increase fluid intake to reduce risk of renal injury; monitor I/O
- educate on place in therapy (may exacerbate acute attacks)
- periodic monitoring of renal function
- admin with food to min GI effects
pegloticase (Krystexxa) MOA
uric acid oxidase class agent that converts uric acid to allantoin which is water soluble and readily excreted by kidneys
pegloticase (Krystexxa) indications
pts not responsive to other PO urate lower therapies
pegloticase (Krystexxa) AEs
- may experince gout flare initially during treatment
- anaphylaxis more common
- infusion rxns common
pegloticase (Krystexxa) nursing considerations
- premedicated w/ antihistamine, acetaminophen, and intravenous glucocorticoid and monitor closely
- infuse med slowly can help reduce symptom intensity of infusion rxns
- more costly
sumatriptan (Imitrex) MOA
abortive triptain class agent that causes selective activation of 5-HT binding to receptors causes vasoconstriction and suppresses release of CGRT to reduce release of inflammatory neuropeptide and neurovascular inflammation
sumatriptan (Imitrex) indications
- moderate to severe migraine
- cluster headache
- off-label use as abortive therapy of cyclic vomiting syndrome
sumatriptan (Imitrex) AEs
- transient chest symptoms, nonischemic related chest pressure and heavy arm sensation
- coronary vasospasm in pts with CAD
- teratogenic
sumatriptan (Imitrex) nursing considerations
- educate on proper admin for migraine treatment
- educate pts to avoid triggers and recognize symptoms of aura that occur prior to onset
- avoid in pts with CAD
- educate on contraception due to risk of fetal harm
alprazolam (Xanax) MOA
benzodiazepine agents that potentiates GABA’s effects by increases neuronal membrane permeability of chloride ions
alprazolam (Xanax) indications
- anxiety disorder and procedural anxiety
- off-label for treatment of vertigo
alprazolam (Xanax) AEs
- CNS and resp depression
- anterograde amnesia
- paradoxical effects
- abuse and misuse
alprazolam (Xanax) nursing considerations
- AEs may be worse with concurrent CNS depressant use
- admin IV flumazenil as a reversal agent due to its benzodiazepine receptor antagonist effects
- monitor for anxiety s/s and progression while on pharmacotherapy along with non-pharmacological treatment measures
zolpidem (Ambien) MOA
hynotic agent that potentiates GABA’s effects via selective agonism at the benzodiazepine-1 receptor to increase chloride conductance to help with insomnia
zolpidem (Ambien) AEs
- CNS depression
- complex sleep behaviors
- psychiatric and behavioral effects (hallucinations, delirium, and worsening of depression)
- withdrawal w/ chronic admin
