Exam 1 Pain & RA Flashcards
1
Q
Types of pain
A
Nociceptive and neuropathic
2
Q
Damage to body tissue causes what type of pain?
A
Nociceptive
3
Q
What type of pain is caused by nerve damage?
A
Neuropathic pain
4
Q
What is the goal of pain management?
A
Reduce peripheral sensation and decrease central simulation
5
Q
1-10 assessment of mild pain?
A
1-3. OTC analgesics such as APAP, ASA, NSAIDs, COX2 inhibitor
6
Q
1-10 assessment of moderate pain?
A
4-7. Combination therapy such as NSAIDs, Opioid + APAP, Tramadol
7
Q
1-10 assessment of severe pain
A
8-10, opioids
8
Q
MOA of APAP
A
Tylenol. Inhibit synthesis of prostaglandins in CNS
9
Q
APAP Dose
A
325-650 mg q4h OR 1000mg Q6h
10
Q
Max APAP dose
A
4g/day
11
Q
APAP- Max dose for liver impairment or alcoholism
A
2g/day
12
Q
Only true analgesic
A
NSAIDs
13
Q
Black box warning for APAP
A
Liver toxicity with 4g/day
14
Q
COX 1 INHIBITION
A
Vasoconstriction, platelet aggregation. Cytoprotective. Prostaglandins and thromboxane
15
Q
COX-1 INHIBITION location
A
GI, kidney, lung protection
16
Q
COX-2 INHIBITION
A
Inflammatory, prostaglandins, prostacyclin. Inflammation, pain, antiplatelet, vasodilation
17
Q
Aspirin - what type of drug?
A
Salicylates
18
Q
MOA Aspirin
A
IRREVERSIBLY binds to COX-1 and COX-2 enzymes
19
Q
Adverse Effect of Aspirin
A
Irreversible antiplatelet. Prevents synthesis of thromboxane A, vasoconstrictor and inducer of platelet aggregation
20
Q
NSAIDs - adverse events
A
GI irritation, respiratory bronchospasms, renal insufficiency or FAILURE
21
Q
OTC NSAIDs
A
Ibuprofen, naproxen
22
Q
Ibuprofen half life
A
2-4h
23
Q
Ibuprofen onset
A
30m-1h
24
Q
Ibuprofen duration
A
4-6h
25
Max dose ibuprofen/day
2400 mg
26
Naproxen half life
12-17h
27
Naproxen onset
1h
28
Naproxen duration
7h
29
Naproxen max dose per day
600mg
30
Indomethacin max dose/day
200mg
31
Ketorolac max dose/day
120mg
32
Warning for NSAIDs
Black box - thrombotic events, GI ulcer/bleeding, thyroid of periop pain in setting of CABG
33
Why are NSAIDs so dangerous?
Easy access, we believe they are safe, combination therapy with other nephrotoxic drugs
34
Ketorolac indications
Short term tx of moderate to severe pain
35
Maximum therapy for ketorolac?
5 days
36
COX-2 inhibitor
Celecoxib (Celebrex)
37
COX 2 inhibitor advantages
Selective, minimal GI effects, no effect on platelet aggregation
38
Disadvantages of COX-2 inhibitor
Renal dysfunction, sulfa allergy, CVS EVENTS
39
Phenanthrenes - which medications?
Morphine, hydromorphone, levorphenol, oxymorphone, codeine, hydrocodone, oxycodone
End in “one” or “enol” except “morphine” and “codeine”
40
Phenylpiperidines - which medications?
Meperidine, fentanyl, sufentanil, alfentanyl, remifentanyl
| End in “nyl”, “nil” — except meperdine
41
Phenylheptanes - which medications?
Methadone
42
Morphine - what is an adverse effect and UNIQUE to morphine?
Histamine release - hypotension, pruritis
43
How is morphine metabolized?
RENAL
44
Morphine - metabolism properties
2 active metabolites, 3-glucuronide (myoclonus, confusion, hallucinations), 6-glucuronide (active analgesia)
45
Morphine dosage — KNOW THIS
IV 2-4mg q4h PRN; PO 15-30 q4h PRN
| **Not the same for opioid dependent people
46
Hydromorphone metabolism
Non-renal, short half life, no active metabolites
47
Hydromorphone IV dosage
IV 0.2-1mg q2-4h PRN
48
Hydromorphone PO dosage
2-4mg q4-6h PRN
49
Methadone metabolism
Renally cleared - adjust for CrCL less than 10 mL/min
50
Patient with advanced CKD, concerned about accumulation of morphine, what is a potential alternative?
Dilaudid. Concerned with lack of renal elimination.
51
Risk of methadone
Prolongation of QTc. Hold or reduce dose if QTc greater than or equal to 500. Caution when using other medications that increase QTc. OR history of seizures
52
Methadone dosage PO
2.5 mg q8-12
53
Methadone dosage IV
2.5-10 mg q8-12h
54
Methadone metabolism
Long half life - biphasic, 8-12h, terminal half life 24-36h. Renally cleared - adjust for CrCL less than 10ml/min
55
Meperidine alternate name
Demerol
56
Meperidine adverse effect
Active metabolite - neurotoxic effects, increased with renal dysfunction
57
Current uses for meperidine
Post-op shivering
58
Codeine unique features
Active metabolite is morphine, major CYP 2D6 substrate, used in combination with APAP or ASA, for mild to moderate pain, low risk for abuse
59
Major feature of codeine
Antitussive
60
Hydrocodone unique features
Combo product with APAP (Vicodin), ibuprofen (vicoprofen), or ER (zohydro, hysingla)
61
Hydrocodone uses
Moderate to severe pain in patients with limited opioid use
62
Fentanyl dosage
IV 25-50 mcg q2-3h
63
Fentanyl metabolism
Preferred for liver failure patients, metabolized by CYP3A4, high potency and lipid solubility - rapid onset
64
Fentanyl routes of administration
Everything but oral, IV or patch, parenteral
65
Fentanyl unique factor
Completely synthetic
66
Fentanyl adverse effects
Bradycardia, chest wall rigidity
67
Naloxone used for what?
Opiate antidote
68
Naloxone metabolism
Repeated dosing may be necessary due to half life of agonist. Not good PO due to extensive first pass
69
Naltrexone
Used PO and IM depot for opioid dependence. Not for acute reversal/toxic effects
70
Naltrexone cautions
Hepatotoxic
71
Methylnaltrexone indicated for?
Opioid induced constipation
72
Methylnaltrexone routes
SubQ
73
Methylnaltrexone metabolism and adverse effects
Renally eliminated, potential risk for GI perforation
74
Tramadol unique aspects
Inhibition of norepinephrine and serotonin reputable, weak opiate mu receptor binding. Less respiratory depression, GI dysmotility
75
Tramadol adverse effects
Decreased seizure threshold
76
Tramadol metabolism
Renal/hepatic, adjust in dysfunction
77
Class wide opioid adverse effects
Respiratory depression, constipation, sedation
78
Important for individuals on opioids
Bowel regimen - stool softener AND stimulant
79
Can you die from opioid withdrawal?
No
80
Addiction vs. dependence
Addiction is mental. Dependence is physical.
81
What are the effects of opioids that you do not develop tolerance to?
Miosis, constipation, seizures
82
Why would you administer a long acting opioid?
Reserved for opioid tolerant patients with chronic pain
83
When would you administer short acting opioids for chronic pain?
For breakthrough pain. Take 10-15 percent of total daily dose of regular schedule and offer immediate release q2-4h PRN
84
When would you increase a long acting dose of opioids for chronic pain individuals?
If pt uses 3 or more doses of breakthrough pain Rx
85
What medications are used for neuropathic pain?
SSRI/SNRI duloxetine, venlafaixine. Tricyclic antidepressants nortiptyline, despiramine. Calcium channel a2 ligands gabapentin, pregabalin
86
Treatment for mild to moderate migraine attack
APAP used with caffeine, NSAIDs
87
Treatment for moderate to severe migraines when nonspecific Rx does not work
Triptans - selective agonists. 5HT (serotonin). Targeted therapy to vasoconstrict intracranial arteries. Most effective when taken 4 hours+ after onset.
88
Triptan contraindications
Heart disease, PVD, CVA, HTN. 2w hx of MAOI.
89
Examples of triptan medications
End in “triptan” — sumatriptan (Imitrex), zolmitriptan (Zomig)
90
Chronic migraines treatment
Prophylactic therapy with a goal to reduce frequency, severity, duration, and improve responsiveness to therapy.
91
Chronic migraine therapy uses what type of medication?
Non-traditional pain medications. Beta blockers, antidepressants, calcium channel blockers, anticonvulsants.
92
Types of medications used for RA
NSAIDs, DMARDs...disease modifying anti rheumatic drugs
93
When should a DMARD medication be started?
Within first 3 months of symptom onset
94
What is a similarity of all DMARDs?
They all effect immune system
95
Characteristic of DMARD?
Reduce mortality, prevent progression of RA
96
First line DMARD for all patients?
Methotrexate
97
Frequency of methotrexate?
Once weekly
98
Characteristic of methotrexate that makes this ideal medication
May be used in combination with any other DMARD
99
Tx for mild forms of RA with less side effects
Hydroxychloroquine (Plaquenil)
100
Humira adverse effects
Risk for infections
101
Alternate name for humira
Adalimumab
102
Reason humira is a favorite tx
One SubQ every other week
103
First oral RA biologic agent
Xeljanz - brand name. Tofacitinib
104
What must RA patients be tested for prior to tx?
TB
105
How often must RA patients be tested for TB?
Annual
106
Cautions for methotrexate & RA medications
Do not initiate or resume while pregnant or breastfeeding
107
Phenanthrenes - all end in?
-ine, -one, -enol
108
Phenylpiperidines all end in?
-nyl, -nil, meperidine
109
Phenylheptanes - end in?
Methadone - only medication
