CHAPTER 4: CNS: Pain Flashcards
Which drug should be avoided in sickle cell disease?
Pethidine
Why should pethidine be avoided in sickle cell disease?
Accumulation of neurotoxic metabolite can precipitate seizures
In dental pain, analgesics can be used in the short term (up to a week) until what?
The cause has been identified and dealt with
Pain and discomfort associated with acute problems of the gastric mucosa may be relieved by which topical preparation?
Difflam
Which class of drug can relieve most dental pain?
NSAIDs
Which class of drug is relatively ineffective in dental pain?
Opioids
Any analgesic given before a dental procedure should have a low risk of increasing what?
Post-operative bleeding
If patients get anxiety due to pain before dental procedures (e.g. by clenching their teeth), which drug may be effective?
Diazepam
Which class of drug can be used as a long-term preventative measure of pain associated with dysmenorrhoea?
Oral anti contraceptive
Other than the oral contraceptive, which 2 drugs can be used for pain in dysmenorrhoea
Paracetamol and ibuprofen
Once known for its analgesic effect, which “NSAID” is now mainly used for its antiplatelet effect?
Aspirin
When should aspirin and other NSAIDs be taken to minimise GI effects?
After food
Aspirin interacts significantly with drugs, which interaction is a special hazard?
Aspirin and Warfarin
Paracetamol is a generally tolerable drug and can be used in children and the elderly. However, in which situation is it particularly dangerous?
in overdosage
How long can paracetamol overdose go undetected?
4-6 days
In which patients are NSAIDs contra-indicated? (5)
- Asthmatics
- Heart failure
- CKD
- Hyperkalaemia
- GORD
What are the side effects of opioids? (6)
- Constipation
- Respiratory depression
- Dependence
4, Sedation - Nausea
- Vomiting
Which combination product is no longer licensed due to safety concerns especially toxicity in overdose?
Co-proxamol (Dextropopoxyphene and Paracetamol)
What can repeated administration of opioids cause? (2)
- Dependence
2. Tolerance
In which situation should the risk of dependece and tolerance not be used as a deterrent?
Terminal illness
What is the most valuable opioid for severe pain?
Morphone
Which opioid has both agonist and antagonist properties?
Buprenorphine
In patients dependent on other opioids, what may buprenorphine precipitate?
Withdrawal symptoms and pain
Which opioid has a greater solubility than morphine so is often preferred in palliative care as larger doses can be administered in smaller volumes?
Buprenorphine
Which opioid analgesic is not recommended after myocardial infarction?
Pentazocine
Which opioid analgesic works by opioid agonism and noradrenaline reuptake inhibition?
Tapentadol
Which opioid analgesic works by opioid agonism and SNRI?
Tramadol
Give 2 examples of weak opioids
- Codeine
2. Dihydrocodeine
Which opioid is not recommended for the treatment of post operative pain?
Pethidine, converted to norpethidine which stimulates CNS and can lead to convulsions
Which device can be used post-operatively to deliver opioids?
PCA
Do doctors require a special license to treat patients with opioid dependence with opioids for organic disease?
NO
There is an increased risk of overdose in patients taking parecatamol if they are what? (2)
- Less than 50kg
2. Poor hepatic function
Paracetamol can interact with which drugs to cause toxicity?
Enzyme-inducing anti-epileptics
If someone overdoses on paracetamol, what are the only clinical features of this in the initial stages?
Nausea and vomiting
Paracetamol capsules and tablets can be sold to the public in packs no larger than how many?
32
What is the total amount of paracetamol tablets / capsules that can be sold OTC?
100
How can respiratory depression in opioid toxicity be reversed?
Using naloxone
As well as coma and respiratory depression, what is another sign of opioid toxicity?
Pin-point pupils
Can opioids be stopped abruptly after long term treatment?
No - gradual withdrawal
Fever and external heat can increase absorption from which patches?
Buprenorphine
What must be monitored before and throughout treatment with buprenorphine?
LFTs
Which 2 opioids are recommended for the treatment of substance misuse?
- Buprenorphine
2. Methadone
How long is supervised consumption for patients on buprenorphine and methadone for dependence?
3 months
Why can the activity of codeine vary so much between populations?
The capacity to metabolise codeine into morphine (active) can vary: ultra metabolisers, poor metabolisers
What are the 2 MHRA alerts for the use of codeine?
- Restricted use in children due to reports of toxicity
2. Codeine for cough and cold restricted for use in children
At which age should codeine be used only for the relief of moderate pain if it cannot be relieved by ibuprofen or paracetamol alone?
Over 12
In which children is there a serious risk of life-threatening adverse reactions? It is therefore contra-indicated
Children with obstructive sleep apnoea whi received it after tonsillectomy or adenoidectomy
What is the maximum duration of treatment for codeine in children 12-18?
3 days
In which children is codeine not recommended?
In those with compromised breathing (e.g. during infection, respiratory/cardiovascular disorders)
What does this mean “Fentanyl 25 patches”?
Fentanyl 25mcg/hr patches
How should used fentanyl patches be disposed?
Removed then folded in on themselves then disposed in a regular bin
Can fentanyl patches be cut?
No
Which CD is morphine 10mg/5mL?
CD5
What are the treatment options for migraine? (4)
- Paracetamol
- Aspirin
- Anti-emetics
- 5HT1 antgonists (e.g. Sumatriptan)
Can Sumatriptan be combined with Naproxen for treatment of migraine?
Yes
Why is it advantageous to treat N&V associated with migraines with Metoclopramide and Domeperidone?
- Promote gastric emptying
2. Promote normal peristalsis
Which drug can trigger migraines?
Combined hormonal oral contraceptives
If a patient suffers more than two migraines a month, what should be considered?
Prophylactic treatment
Which formulation of analgesia is most suitable for treating migraines?
Soluble/dispersible because peristalsis is reduced and tablets may not be well absorbed
Which class of drug, associated with cardiovascular treatment, can be effective in the prophylaxis of migraine?
Beta-blockers
Which is the most commonly used beta-blocker for the prophylaxis of migraine
Propranolol
Give 5 unlicensed treatments for migraine prophylaxis
- TCAs
- Topiramate
- Sodium valproate
- Valproic acid
- Gabapentin
What are the active ingredients of migraleve yellow?
Paracetamol + Codeine
What are the active ingredients of migraleve pink?
Paracetamol + Codeine + Buclizine
How should migraleve tablets be taken for migraine?
TWO PINK tablets at onset
TWO YELLOW tablets every 4 hours PRN
MAX = 8 in one day
How should sumatriptan be taken for migraine?
1-2 tablets initially followed by 1-2 tablets after 3 hours if required
Can sumatriptan be sold OTC?
Yes, for previously diagnosed migraine
Give 5 causes of neuropathic pain
- HIV infection
- Diabetes
- Chronic excessive alcohol
- Chemotherapy
- Idiopathic
What is postherpetic neuralgia?
Peripheral nerve damage following acute herpes zoster infection
Which drugs are generally used to manage neuropathic pain?
- TCAs
2. Anti-epileptics
Give an example of topical application which can be used to treat neuropathic pain in patients unable to tolerate oral medicines
Lidocaine plasters
