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neuro 2 > exam 2 BONUS- pharm management of chronic pain > Flashcards

exam 2 BONUS- pharm management of chronic pain Flashcards

1
Q

treatment of chronic pain requires —-

A

physical medicine and pharmacological and psychological management protocols

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2
Q

most patients with chronic orofacial pain are ______ not _____

A

managed, not cured

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3
Q

limitations of pharm management of chronic orofacial pain

A
  • empirical (clinical evidence)
  • lack of randomized clinical studies
  • challenging bc of fluctuations in conditions
  • treatments assoc. with significant placebo effect
  • lack of adequate pts with more specific condition
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4
Q

musculoskeletal orofacial pain

A
  • myalgia
  • myofacial pain
  • TMJ
  • arthritis
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5
Q

neuropathic pain

A

trigeminal neuralgia, other chronic pain

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6
Q

neurovascular disorders

A
  • tension headache
  • migraine
  • cluster headache
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7
Q

drug categories for chronic orofacial pain

A 
muscle relaxants
-NSAIDs
corticosteroids
antidepressants
antiseizure
alpha adrenergic blockers
triptains
topical agents
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8
Q

treatment of musculoskeletal pain

A
  • physical med and medications with emphasis on physical meds
  • muscle relaxants for acute pain
  • sleep and pain tied together
  • blocking histamine relieves muscle stiffness and pain and promotes sleep
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9
Q

muscle relaxant examples

A 
cyclobenzaprine (flexeril)
carisoprodol (soma)
methocarbamol (roboxin)
diazepam (valium)
baclofen (lioresal)
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10
Q

cyclobenzaprine (flexeril)

A
  • mode of action unknown
  • acts in CNS (locus coeruleus)
  • increases norepinephrine inhibiting alpha motor neurons in ventral horn of spinal cord and causing decreased muscular tone
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11
Q

carisoprodol (soma) and methocarbamol (roboxin)

A
  • relaxation of voluntary muscles through depressant action on CNS
  • alterations in neuronal excitability involved
  • reduce neuronal activity in brainstem, thalamus, and basal ganglia
  • depression of spinal cord interneurons
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12
Q

diazepam (valium)

A

facilitates inhibitory actions of GABA on neurons

causes skeletal muscle relaxation

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13
Q

baclofen (lioresal)

A

analog of GABA and agonist for subset of GABA receptors (I.e. GABAb)

  • may inhibit motor tone by decreasing release of excitatory amino acid transmitters
  • may decrease calcium conductance and/or increase potassium conductance
  • indicated for multiple sclerosis or traumatic spinal cord injury
  • treatment for trigeminal neuralgia
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14
Q

ketorolac (torodol)

A
  • acute and pre-emptive pain management (TMJ mobilization with lysis, lavage, and manipulations)
  • can cause renal impairment
  • should not be used in those with serum creatinine > 5 mg/dL
  • limit to 5 days
  • oral and parenteral
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15
Q

diclofenac sodium

A
  • oral, topical gel and patch
  • TMJ pain
  • topical agent useful for TMJ capsulitis and myalgia associated with TM disorders
  • oral diclofenac combined with misoprostol limits GI side effects
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16
Q

naproxen sodium

A

preferred NSAIDs for treatment of TMJ (500 mg bid due to longer half life)

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17
Q

adrenocorticosteroids treat—

A

acute inflammatory pain, headache and neuropathic pain

high dose tapered off

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18
Q

mechanisms of adrenocorticosteroids

A

modulation of GABAa receptors located outside BBB suppresses neurogenic inflammation

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19
Q

intra-articular therapy

A

reduces pain and swelling assoc with inflammatory disease of muscles and joints

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20
Q

cortisone and hydrocortisone

A

inject into joint

beneficial but diffuse out rapidly, lacking sustained effect

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21
Q

betamethasone

A

disodium phosphate ester used with insoluble acetate ester –> RAPID effect from phosphate ester and SUSTAINED effect from acetate ester
(adreno)

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22
Q

triamcinolone acetonide

A

low solubility and long duration

adreno

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23
Q

how many steroid shots can you get?

A

up to three with 4 week period between injections

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24
Q

when are antidepressants used?

A
  • chronic orofacial pain can cause depression, anxiety, and reduced quality of life
  • when other options are not enough and pain is accompanied by depression
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25
Q

most effective antidepressant

A

tricyclic antidepressant with effects on both serotonin and norepinephrine
(amitriptyline and nortriptyline)

26
Q

nortriptyline

A

TCA

better tolerated than amitriptyline

27
Q

duloxetine and venlafaxine (SNRIs)

A

used for chronic muscle pain and neuropathic pain

  • patients with fibromyalgia
  • improvements in quality of life but adverse effects for duloxetine, esp nausea and dry mouth
28
Q

SSRIs examples

A

escitalopram
citalopram
fluoxetine

29
Q

SSRIs are effective for treating ______ associated with _____

A

anxiety assoc with chronic neuropathic pain

30
Q

SSRIs have more favorable adverse effects than _____

A

TCAs

31
Q

treatment for chronic mastigatory myofascial pain

A

botulinum toxin type A

32
Q

mechanism of botox

A

reduction in neurogenic release of pain causing substances such as glutamate, calcitonin-gene-related peptide and substance P by masticatory nociceptors to reduce pain in tender region of the muscle

33
Q

common neuropathies in orofacial region

A 
trigeminal neuralgia
traumatic trigeminal neuropathy
posterpetic neuralgia
diabetic neuropathy
cancer-induced neuropathy 
AIDs induced neuropathy
34
Q

diagnostic criteria for trigeminal neuralgia

A
  • episodic sharp pain with periods of remission
  • no obvious local cause
  • pain triggered with minor stimulation
  • normal radiograph
  • normal thermography
  • positive block (nerve block relieves pain)
  • sympathteic block does not define this disorder
35
Q

most common neuropathy seen in orofacial region

A

trigeminal neuralgia

36
Q

gold standard for treatment of trigeminal neuralgia

A

anti-seizure meds (carbamazepine, oxacarbazine, gabapentin)

37
Q

carbamazepine

A

gold standard for trigeminal neuralgia
use dependent Na + channel blocker inhibiting repetitive discharges
-liver tests and complete blood count required
-extended release formulation
-induces CYP3A4 enzyme system which also accelerates its own metabolism; required dose adjustment 1-2 weeks of therapy

38
Q

oxcarbazepine

A
  • like carbamazepine but doesn’t induce liver enzymes
  • better tolerability and safety margin
  • does not require LFT and CBC monitoring but does require electrolyte monitoring for Na (can cause hyponatremia
  • can be titrated more rapidly than carbamazepine –helpful in pts in acute trigeminal neuralgia
39
Q

gabapentin

A
  • analog of GABA but decreases hyperalgesia thru selective inhibition of subunits of voltage dependent L-type Ca++ channels
  • this ion channel maintains mechanical hypersensitivity in neuropathic pain–suppresses but does not stop, neuronal activity
  • side effects–relatively benign (drowsiness, nausea and fatigue) compared to other anti-seizure meds
40
Q

are antidepressants more or less effective than carbamazepine?

A

less

41
Q

how do adrenocorticosteroids work?

A

following nerve injury–> neuroma forms in proximal part–> neuronal sprouts–> spontaneous discharge–> steroids reduce neuronal activity bc of stabilization of neuronal membrane conductivity
-injection into neuroma

42
Q

sodium channel subtype inhibitors

A

(local anesthetics)

  • lidoderm (5% lidcaine patch) useful in management of peripheral neuropathic conditions
  • FDA approved for post-herpetic neuralgia
43
Q

treatment of abortive migraine

A
  • nonopioid analgesic for mild to moderate
  • triptan for moderate to severe migraine
  • use of opioids and butalbital for migraine treatment is discouraged
44
Q

short acting oral triptains

A 
sumatriptan
almotriptan
eletriptan
rizatriptan
zolmitriptan
*all similar in efficacy and speed of onset
45
Q

____ triptan have faster onset of action than oral triptans

A

intranasal

46
Q

_______ is the fastest acting and most effective triptan formulation

A

subcutaneous sumatriptan

47
Q

prevention (prophylaxis) of migraine

A

topiramate, valproate, and beta blockers (propranolol, timolol, and metoprolol)

48
Q

burning mouth syndrome

A
  • burning pain in mouth every day for months+
  • oral mucosa appears normal
  • disorder of peripheral nerves with central brain changes
  • no specific test
  • most commonly seen in peri- and post-menopausal women
  • no specific treatment
  • poor prognosis but won’t get worse
49
Q

symptoms of burning mouth

A
  • burning, scalding, tingling in mouth or numbness
  • dry mouth or altered taste
  • painful
  • usually tongue but can also be in lips or roof of mouth or throughout mouth
50
Q

primary BMS

A

burning mouth syndrome
if tests do not reveal an underlying medical problem
-caused by damage to nerves that control pain and taste

51
Q

secondary BMS

A

treating medical problem will cure secondary BMS

  • hormonal changes
  • allergies
  • dry mouth
  • meds
  • nutrient deficiencies
  • infection
  • acid reflux
52
Q

treatment of BMS

A
  • depends on person
  • go away when underlying medical condition is treated
  • sip cold beverage, melt ice chips in mouth, chewing gum
  • avoid irritating substance
  • topical capsaicin and clonazepam
  • systemic capsaicin for mouth –> gastric probs but good result
  • combination of gabapentin with lipoic acid (antioxidant)
53
Q

advantage of topical agents

A

direct application to tx area
decrease side effects
direct effects on local receptors may have greater benefits than systemic application

54
Q

topical meds are incorp in ______ for skin app or _____ for oral app

A
  • pleuronic lecithin organogel (PLO) for skin

- orabase for oral

55
Q

PLO

A

pleuronic lecithin organogel
penetrates epidermal barrier, carrying the agent to the locus
-systemic admin also occurs

56
Q

triamcinolone (kenalog)

A

orabase

composed of gelatin, pectin, and sodium carboxymethylcellulose in plastibase

57
Q

capsaicin-responsive vanilloid receptors

A

on small-diameter unmyelinated nociceptors (C fibers)

  • target of novel sites of drug action
  • TRPV1 receptors
58
Q

capsiacin action

A

causes release and eventual depletion of neuronal stores of substance P, eventually causing inhibition of neuronal ability to synthesize more SP

59
Q

persistent application of capsaicin does what?

A

desensitizes chronic peripheral neuropathy, causing relief from pain

60
Q

how is capsiacin applied?

A

intraorally
-with acrylic stent and 0.025% capsaicin mixed with orobase-b paste to give sticky quality to hold in place and limit dispersion throughout the oral cavity

61
Q

topical agents examples

A

ketamine, eutectic mixtures of local anesthetics (EMLA) and 5% lidocaine patch (lidoderm)

neuro 2 (3 decks)

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