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OTC > Exam 3 - Analgesics and Antipyretics > Flashcards

Exam 3 - Analgesics and Antipyretics Flashcards

1
Q

What are analgesics used for

A

Pain

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2
Q

Medication can act in the _____ and the ________

A

CNS
PNS

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2
Q

What are antipyretics used for

A

Fever

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3
Q

What does visceral mean?

A

Deep seated, organ related pain

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4
Q

What are prostaglandins

A

Hormone-like lipids

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5
Q

What effects do prostaglandins have

A

Bodily functions such as:
- inflammation
- pain
- uterine contraction
- “much more”

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6
Q

What is the natural role of prostaglandins

A

In defense and repair

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6
Q

Obtundation

A

Level of consciousness between alertness and coma just like “stupor” and lethargy

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7
Q

What are caplets

A

Tablets that are shaped like a capsule, that are smaller than a tablet, but have a smoother finish to allow for easy swallowing

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8
Q

Characteristics of obtundation

A
  • reduced alertness
  • slow response to stimuli
  • less interested in environment
  • tends to sleep more than normal (but w/ continued drowsiness between sleep)
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9
Q

Wong Baker pain assessment tool

A

Universal pain assessment tool

Tool intended to help patients care providers assess pain according to individual pt needs

0-10 scale for patient self assessment

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9
Q

FPS-R

A

Faces Pain Scale Revised (faces)

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10
Q

What can PCPs use if the pt is not able to communicate his/her pain intensity

A

Wong baker faces or behavioral observations

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11
Q

Iowa Pain Thermometer (IPT)

A

Looks like a thermometer (no pain to most intense pain imaginable)

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12
Q

PEG scale

A
  • what # describes your pain in the last week 0-10
  • what # best describes how, in the last week, pain has interfered w/ your enjoyment of life 0-10
  • what # best describes how, during the last week, pain has interfered w/ your general activity 0-10
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13
Q

Psychometric testing of the defense and veterans pain rating scale (DVPRS) - 2016

A

4 supplemental questions measure how much pain interferes with:
- usual activity
- sleep
- mood
- stress

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14
Q

Non-pharmacological for pain

A

Relaxation therapies
Cognitive behavioral therapy
Physical modalities including:
- acupuncture
- chiropractic
- massage
- physical therapy
- osteopathic manipulation

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14
Q

Somatic pain

A
  • superficial (on the skin or musculoskeletal system)
  • easy to pinpoint location
  • ACUTE MOST OF THE TIME
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15
Q

Visceral pain

A
  • deep seated, organ related
  • difficult to pinpoint
  • CHRONIC MOST OF THE TIME
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16
Q

Examples of acute pain

A

Headache
Musculoskeletal pain
Dysmenorrhea

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17
Q

What is special about treatments for chronic pain

A

It requires prescription treatment and supervised medical care

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17
Q

Examples of chronic pain

A

Cancer
AIDS
Arthritis
Chronic back pain
Neuropathy

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18
Q

Why are toothaches no longer considered acute pain

A

Toothaches require referral

Can counsel on short term use until patient can see a dentist

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19
Q

Indication of acetaminophen

A

Fever and mild-moderate non-visceral pain

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20
Q

Acetaminophen absorption

A

Well absorbed from the GI tract

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21
Q

acetaminophen MOA

A

Thought to act centrally to inhibit prostaglandin synthesis as one pathway (but not well understood and complex)

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22
Q

Analgesic onset of acetaminophen

A

30 min

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22
Q

Analgesic duration of acetaminophen

A

4 hrs

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23
Q

Rectal admin of acetaminophen

A

Less bioavailable than the oral admin by 50-60%

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24
Q

Antipyretic onset of acetaminophen

A

30 min - 1 hour

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25
Q

When is max temperature reduction for using acetaminophen for fever

A

2 hours after taking

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26
Q

What is acetaminophen METABOLIZED by

A

Liver

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27
Q

What is acetaminophen EXCRETED by

A

Kidneys

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27
Q

What can happen if you exceed the max dose of 4 g of acetaminophen

A

Potentially hepatotoxicity, especially w/ chronic use

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28
Q

How much acetaminophen should someone take if they are at an increased risk for acetaminophen induced hepatotoxicity

A

Complete avoidance or conservative dosing of 2 g or less per day

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29
Q

Who is at increased risk for APAP induced hepatotoxicity

A
  • liver disease
  • concurrent use of other potentially hepatic drug
  • poor nutritional intake
  • consumption of 3+ alcoholic drinks per day
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30
Q

What is considered one alcoholic drink

A

12 oz beer
5 oz wine
1.5 oz of 80 proof liquor

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31
Q

Proof (alcohol)

A

The measure of alcohol content in a beverage

TWICE THE % ABV

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31
Q

Commercial formulation of acetaminophen

A

Rectal suppositories
Liquid
Liquid gels
Tablets
Powder packs that dissolve in liquid

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32
Q

Types of tablets in APAP

A

Caplets
Chewables

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33
Q

Dosing of IR APAP for adults

A

325 mg tabs
3250 mg per day OTC

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34
Q

Dosing of extra strength APAP for adults

A

500 mg
3000 mg per day OTC

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35
Q

APAP pediatric dosing

A

10-15 mg/kg/dose q4-6h PRN

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35
Q

Dosing of ER APAP for adults

A

650 mg
3900 mg per day OTC

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36
Q

Max adult APAP daily dose

A

4000 mg per day under HCP supervision

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37
Q

Max pediatric APAP dose

A

480 mg/dose, up to 5 doses
OR
75 mg/kg/day

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37
Q

How much APAP should you not exceed for pediatrics per day

A

2400 mg/day

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38
Q

FDA recommendations for APAP dosing

A

The lower max daily limits and that pediatric ORAL dosage forms be limited to a single strength (160 mg)

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39
Q

Stage 1 APAP toxicity

A

Nausea/vomiting
Drowsiness
Confusion
Abdominal pain

EARLY SIGNS AND SYMPTOMS MIGHT BE DELAYED

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40
Q

Stage 2 APAP toxicity

A
  • first signs of hepatotoxicity
  • begins 24-48 hrs after acute ingestions
  • increased AST and ALT liver enzymes
  • increased bilirubin w/ jaundice
  • prolonged prothrombin time
  • obtundation
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41
Q

Stage 3 APAP toxicity

A
  • develops after 3-4 days and progresses to liver failure without treatment
  • metabolic acidosis, encephalopathy, cerebral edema, renal failure
  • may have continuous GI symptoms
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42
Q

Stage 4 APAP toxicity

A
  • begins 4 days after ingestion
  • can last weeks
  • hepatic damage is reversible for the majority of cases
  • some may need liver transplant
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43
Q

Antidote for APAP poisoning

A

N-acetylcysteine

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44
Q

What is the need for using N-acetylcysteine determined by

A

Rumack-Matthew nomogram

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45
Q

Warfarin-APAP interaction

A
  • increased bleeding risk
  • regular use of APAP while pt on warfarin should be discouraged
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45
Q

Clinically important APAP drug interactions

A

Alcohol
Warfarin

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46
Q

Severe liver damage may occur if…

A

An adult takes > 4 g of APAP in 24 hours

A child takes > 5 dosages in 24 hours (max daily amount)

The product is taken w/ other drugs that contain APAP

An adult has 3+ alcoholic drinks/day while using APAP

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47
Q

Limit of APAP in opioid rx combo products

A

325 mg/dosage unit

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47
Q

Analgesic of choice for warfarin patients

A

APAP

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48
Q

NSAIDs

A

Ibuprofen (motrin, advil)
Naproxen (aleve)

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49
Q

Acetylated salicylate NSAID

A

Aspirin

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50
Q

Non-acetylated salicylate NSAID

A

Magnesium salicylate

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51
Q

OTC naproxen strength

A

220 mg

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51
Q

OTC ibuprofen strength

A

200 mg tabs

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52
Q

MOA of NSAIDs (ibu + naproxen)

A

Central AND peripheral inhibition of COX, which then inhibits prostaglandins synthesis

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53
Q

Indication of NSAIDs

A

Fever
Mild-moderate non-visceral pain

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54
Q

NSAIDs metabolism/excretion

A

Metabolized by liver
Eliminated by kidneys

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54
Q

Onset of NSAID analgesic activity

A

30 min

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55
Q

Duration of analgesic activity for ibuprofen

A

6-8 hours

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55
Q

NSAIDs absorption

A

Well absorbed from the GI tract

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56
Q

Duration of analgesic activity for naproxen

A

12 hours

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57
Q

Warnings for NSAIDs

A

CHR may be exacerbated by NSAID use

Increased risk of renal toxicity in certain populations

58
Q

Risk factors for renal toxicity in ibuprofen use

A

Advanced age
HTN
Diabetes mellitus
Using diuretics
Atherosclerotic CV disease

(Ass Holes Don’t Usually Ask)

59
Q

Contraindications for NSAIDs

A

Contraindicated for perioperative pain after CABG surgery

60
Q

Common adverse reactions w/ NSAIDs

A

Dyspepsia
Epigastric pain
Nausea
Anorexia
Dizziness
GI upset
Heartburn
Nervousness
Fatigue

(Don’t Eat Nsaids All Day, Gonna Have No Fun)

61
Q

Uncommon adverse reactions w/ NSAIDs

A

Rash
Pruritis
Photosensitivity
Fluid retention/edema

62
Q

Serious and rare adverse reactions w/ NSAIDs

A

GI ulceration
Perforation
Bleeding

63
Q

Risk factors for serious adverse reactions w/ NSAIDs

A
  • 60+
  • Previous ulcer disease
  • Concurrent use of anticoagulant (including aspirin)
  • High doses
  • Long treatment duration
  • 3+ alcoholic drinks/day
64
Q

What is a serious problem that NSAIDs can cause

A

Premature closing of ductus arteriosus, which may lead to heart failure in the infant

65
Q

What do the adverse reactions of NSAIDs tell us

A
  • use caution (or avoid) in renal failure
  • can increase BP
  • can cause nausea and upset stomach
  • photosensitivity
  • do not use in 3rd trimester of pregnancy (30+ weeks)
66
Q

OTC commercial formulations of ibuprofen

A

Liquid
Tablet/caplet
Capsule
Liquid gels

67
Q

OTC commercial formulations of naproxen

A

Capsules
Tablets/caplets
Gel caps
Liquid gels

67
Q

AleveX

A

Available as topical lotions and sprays OTC

Does NOT contain naproxen

67
Q

Motrin

A

Topical gel available

Does NOT contain ibuprofen

68
Q

Adult ibuprofen dosing

A

200 - 400 mg q6-8h PRN

69
Q

Daily max of ibuprofen OTC

A

1.2 g per day

69
Q

Pediatric OTC ibuprofen dosing

A

5-10 mg/kg/dose q6-8h PRN

70
Q

Pediatric OTC ibuprofen daily max

A

300 mg per dose, up to 4 doses
OR
40 mg/kg/day

71
Q

Pediatric OTC ibuprofen dosing should not exceed

A

1200 mg/day

72
Q

Naproxen OTC dosing

A

200 mg (220 mg naproxen sodium) q8-12h

73
Q

Max OTC naproxen dosing

A

3 tablets in 24 hours

74
Q

How much naproxen sodium is equal to regular 200 mg naproxen

A

220 mg naproxen sodium

74
Q

How should you take ibuprofen liquid

A

Take with food or milk to help with stomach upset

74
Q

How should you take ibuprofen tablets

A

Take with a full glass of water

75
Q

What should happen w/ ibuprofen suspensions

A

Shake well

76
Q

Why is naproxen sometimes preferred over ibuprofen

A

Naproxen has less frequent dosing (BID)

A good option for people struggling with adherence

76
Q

Ibuprofen toxicity

A
  • overdose rarely fatal
  • minimal signs and symptoms of toxicity
77
Q

GI manifestations of ibuprofen toxicity

A

Nausea
Vomiting
Diarrhea
Abdominal pain

78
Q

Most serious effects of large naproxen overdose

A

Renal; failure
Neurological toxicity
Acid base changes

79
Q

Drug interactions of ibuprofen

A

Alcohol (increased GI bleed risk)

Increased bleeding risk when taken w/ other agents that increase bleeding risk

80
Q

Drug interactions of naproxen

A

Increased lithium and methotrexate levels when taken with NSAIDs

Multiple NSAIDs should not be used together

81
Q

When can multiple NSAIDs be used together

A

NSAIDs used with low dose aspirin for cardio protection

82
Q

Signs and symptoms of upper GI bleed

A

Hematemesis (vomiting bright red blood)

Coffee ground emesis

Melena (dark, tarry stool)

83
Q

Signs and symptoms of lower GI bleed

A

Hematochezia (right red/fresh blood in feces)

84
Q

Signs and symptoms of nonspecific GI bleed

A

Epigastric pain
Anemia
Syncope
Fatigue

85
Q

Trade names for aspirin

A

Vazalore
St Joseph’s
Ecotrin
Bayer

85
Q

Who is at increased risk for upper GI bleed

A

History of stomach bleed/ulcer

60+ years old

Concurrent use of NSAIDs, anticoagulants, and antiplatelet agents

Concurrent use of systemic corticosteroids

Infection w/ H pylori

Consumption of 3 or more alcoholic drinks per day

Use of aspirin/NSAID for longer than directed

86
Q

Indication of salicylate NSAIDs (aspirin)

A

Analgesic
Antipyretic

87
Q

MOA for aspirin

A

Inhibits COX-1 and COX-2, which inhibits prostaglandin synthesis

Primary peripheral action

87
Q

Aspirin is hydrolyzed to _______

A

Salicylic acid

88
Q

Absorption of aspirin

A

Well absorbed from GI tract

89
Q

Rectal absorption of aspirin

A

Slow and unreliable

89
Q

Onset of aspirin analgesic activity

A

30 min

90
Q

What medications can be used in patients w/ an aspirin intolerance

A

APAP and methyl salicylate

90
Q

Warnings for aspirin use

A

Avoid in children and teens due to Reye’s syndrome risk

In general, avoid other NSAIDs if patient has aspirin intolerance

Avoid in people w/ history of gout or hyperuricemia

Avoid use in patient w/ nasal polyps

Avoid use in patients with asthma

(for mnemonic: Nasal polyps, NSAIDs, Gout, Reye’s, Asthma)

(Never Never Give Real Aspirin)

90
Q

Duration of aspirin analgesic activity

A

About 4-6 hours

91
Q

What is the effect of patients with history of gout taking aspirin

A

Aspirin may cause reemergence of gout if used 2+ days

92
Q

Asthma sensitivity and aspirin use

A

Not really allowed

10% of people with asthma have aspirin sensitivity

93
Q

Two types of serious intolerance to aspirin

A

Cutaneous
Respiratory

94
Q

Cutaneous intolerance to aspirin reactions

A

Edema
Angioedema

94
Q

Respiratory intolerance to aspirin reactions

A

Bronchospasm
Laryngospasm
Rhinorrhea

95
Q

Contraindications for aspirin

A

History of bleeding disorder (hemophilia)

Vitamin K deficiency

Hypoprothrombinemia

History of peptic ulcer disease

(For mnemonic: Hypoprothrombinemia, Bleeding, K, Peptic)

(Having Burger King Pizza)

96
Q

Common adverse reactions to aspirin

A

Upset stomach (dyspepsia)
Heartburn
Bleeding
Nausea

97
Q

Severe adverse reactions to aspirin

A

Stevens Johnson syndrome rash
Toxic epidermal necrolysis rash
GI ulceration and bleeding

97
Q

When should pregnant people avoid using aspirin

A

Avoid in third trimester due to fetal harm

98
Q

Commercial formulations of aspirin

A

Tablets (regular and chewable)
Liquid filled capsules (vazalore)

99
Q

Which aspirin brand is formulated as liquid filled capsules

A

Vazalore

100
Q

Commercial strengths of aspirin

A

81 mg
300 mg
325 mg
500 mg

101
Q

Analgesic dosing for aspirin

A

325-650 mg q4-6h

102
Q

Cardioprotective dosing for aspirin

A

81-162 mg once daily

103
Q

Signs and symptoms of salicylism toxicity

A

Occasional diarrhea
Lassitude
Dizziness
Drowsiness
Hyperventilation
Confusion
Nausea and vomiting
Headache
Sweating and thirst
Tinnitus

(OLD Damn Hags Can Never Have Salicylism Toxicity)

103
Q

Salicylism toxicity in aspirin use

A

Chronic toxic blood levels for at least 2 days

104
Q

Salicylate intoxication due to aspirin

A

Higher blood levels than salicylism

Clinical manifestations depend on blood concentration

104
Q

How is salicylate intoxication characterized

A

Mild
Moderate
Severe

105
Q

Signs and symptoms of salicylate intoxication

A

Dehydration
Tachypnea
Acid base disturbances
Tinnitus
Pulmonary edema
Hemorrhage
Nausea and vomiting
Convulsion
Coma
Lethargy

(Don’t Take Aspirin To Prevent Hearing New Cat Calling Losers)

106
Q

Important drug interactions in aspirin

A

Alcohol

Increased bleeding risk when taken w/ other agents that increase bleeding risk

Increased levels of lithium and methotrexate when taken w/ an NSAID

Multiple NSAIDs should not be used together

106
Q

Salicylates are known to be

A

Ototoxic

107
Q

Aspirin toxicity reactions in children

A

High fever
Serious hypoglycemia

108
Q

Antidote for aspirin toxicity given in the ER setting

A

Gastric lavage or activated charcoal

109
Q

What does taking an enteric coating with food produce

A

Longer absorption time due to prolonged gastric emptying time

109
Q

When should you stop use of aspirin

A

3 days before a fecal testing

2-7 days before surgery

Do not use OTC aspirin for pain after tonsillectomy, dental extraction, or other surgical procedure

109
Q

If the stomach acid is low (due to acid-suppressing meds like a PPI), what might happen to a product with an enteric coating

A

Product may dissolve in the stomach, which can cause stomach irritation

109
Q

What can the use of aspirin produce

A

Positive result on fecal occult blood testing

110
Q

Does enteric coating decrease the risk of GI bleed

A

NO

It is advertised as safer, but isn’t actually

110
Q

When should you NOT use an enteric coated product

A

If you are in need of rapid pain relief

111
Q

Buffered dosage forms

A

Tablet and effervescent forms

112
Q

What is the point of a buffered dosage form

A

Combines an antacid w/ aspirin to absorb more rapidly

113
Q

Common buffer dosage forms

A

Calcium carbonate
Aluminum hydroxide
Magnesium hydroxide
Sodium bicarbonate

(CAMS)

114
Q

Effervescent tablets

A

Use the sodium bicarb and may contain large amounts of sodium

Watch for patients on sodium reduced diets

115
Q

*What should you be aware of before recommending effervescent tablets to a patient

A

Make sure they are not on a sodium reduced diet because they often have a very high sodium content

116
Q

Do buffered dosage forms decrease the risk of GI bleed

A

NO

Marketed as safer but isn’t actually

117
Q

What does the progressive neurologic damage in Reye’s syndrome START with? What does it progress to?

A

Starts w/ lethargy

Progresses to:
- delirium
- confusion
- seizures

117
Q

What is Reye’s syndrome

A
  • progressive neurologic damage
  • fatty liver encephalopathy
  • hypoglycemia
  • mortality rate around 50%
118
Q

Reye’s syndrome happens in what patient population

A

Almost exclusively in children and teenagers

119
Q

Cause of Reye’s syndrome

A

Cause is technically unknown

Using salicylate to treat a viral illness such as flu and chicken pox is associated w/ it

120
Q

What does aspirin do to platelet function

A

Irreversibly inhibits platelet function

Meaning the inhibition continues for the duration of the platelet’s life

121
Q

Salicylate NSAID legal requirements

A

GI risks
Cardiovascular risks
Contraindicated w/ CABG
Alcohol
Reye’s syndrome

122
Q

Motrin dual action combination products

A

Acetaminophen and ibuprofen

123
Q

Advil dual action combination products

A

Acetaminophen and ibuprofen

124
Q

Bayer back and body combination products

A

Aspirin and caffeine

125
Q

Excedrin combination products

A

Acetaminophen
Aspirin
Caffeine

125
Q

BC combination products

A

Aspirin and caffeine

126
Q

Max strength BC combination products

A

Acetaminophen
Aspirin
Caffeine

127
Q

OTC analgesic use in the elderly population

A

Acetaminophen may be the safest

Increased risk of NSAID adverse reactions

More likely to have renal issues

More vulnerable to GI toxicity and HTN/renal impacts

127
Q

Aspirin use in pregnancy

A

No aspirin in pregnancy, ESPECIALLY in the 3rd trimester

127
Q

Which OTC analgesics can be used in children 2+

A

Acetaminophen
Ibuprofen

128
Q

Which analgesics can be used in children 12+

A

Acetaminophen
Ibuprofen
Naproxen

128
Q

NSAID use in pregnancy

A

NSAIDs are not shown to be teratogenic

Contraindicated in 3rd trimester

129
Q

Acetaminophen use in pregnancy

A

Crosses the placenta but is considered safe for pregnancy

129
Q

Which analgesic is preferred in breastfeeding patients

A

Ibuprofen

It is considered the safest because of the very low concentration in breastmilk and lack of ill effect in infants

130
Q

Acetaminophen use in infants

A

Crosses into breastmilk at a low ration

**may cause rash in infants that subsides after discontinuation

131
Q

Naproxen use in breastfeeding

A

DO NOT USE

132
Q

Aspirin use in breastfeeding

A

DO NOT USE

133
Q

Renal impairment

A

Caution w/ salicylates and other NSAIDs

Ask renal doctor to recommend

134
Q

Hepatic impairment

A

Caution to be used w/ acetaminophen

Prolonged use/high doses must be avoided

135
Q

Aspirin allergy

A

15% tartrazine cross reactivity

This is because tartrazine is a yellow dye #5

136
Q

If a person is allergic to aspirin, what is their cross reactivity with APAP, ibuprofen, and naproxen

A

7% cross reactivity w/ APAP
98% cross reactivity w/ ibuprofen
100% cross reactivity w/ naproxen

137
Q

Dosing preference

A
  • BID dosing w/ naproxen
  • ER APAP dosed q8h

OTC (21 decks)

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