Exam 3 - Analgesics and Antipyretics Flashcards
1
Q
What are analgesics used for
A
Pain
2
Q
Medication can act in the _____ and the ________
A
CNS
PNS
2
Q
What are antipyretics used for
A
Fever
3
Q
What does visceral mean?
A
Deep seated, organ related pain
4
Q
What are prostaglandins
A
Hormone-like lipids
5
Q
What effects do prostaglandins have
A
Bodily functions such as:
- inflammation
- pain
- uterine contraction
- “much more”
6
Q
What is the natural role of prostaglandins
A
In defense and repair
6
Q
Obtundation
A
Level of consciousness between alertness and coma just like “stupor” and lethargy
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
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)
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
9
Q
FPS-R
A
Faces Pain Scale Revised (faces)
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
11
Q
Iowa Pain Thermometer (IPT)
A
Looks like a thermometer (no pain to most intense pain imaginable)
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
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
14
Q
Non-pharmacological for pain
A
Relaxation therapies
Cognitive behavioral therapy
Physical modalities including:
- acupuncture
- chiropractic
- massage
- physical therapy
- osteopathic manipulation
14
Q
Somatic pain
A
- superficial (on the skin or musculoskeletal system)
- easy to pinpoint location
- ACUTE MOST OF THE TIME
15
Q
Visceral pain
A
- deep seated, organ related
- difficult to pinpoint
- CHRONIC MOST OF THE TIME
16
Q
Examples of acute pain
A
Headache
Musculoskeletal pain
Dysmenorrhea
17
Q
What is special about treatments for chronic pain
A
It requires prescription treatment and supervised medical care
17
Q
Examples of chronic pain
A
Cancer
AIDS
Arthritis
Chronic back pain
Neuropathy
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
19
Q
Indication of acetaminophen
A
Fever and mild-moderate non-visceral pain
20
Acetaminophen absorption
Well absorbed from the GI tract
21
acetaminophen MOA
Thought to act centrally to inhibit prostaglandin synthesis as one pathway (but not well understood and complex)
22
Analgesic onset of acetaminophen
30 min
22
Analgesic duration of acetaminophen
4 hrs
23
Rectal admin of acetaminophen
Less bioavailable than the oral admin by 50-60%
24
Antipyretic onset of acetaminophen
30 min - 1 hour
25
When is max temperature reduction for using acetaminophen for fever
2 hours after taking
26
What is acetaminophen METABOLIZED by
Liver
27
What is acetaminophen EXCRETED by
Kidneys
27
What can happen if you exceed the max dose of 4 g of acetaminophen
Potentially hepatotoxicity, especially w/ chronic use
28
How much acetaminophen should someone take if they are at an increased risk for acetaminophen induced hepatotoxicity
Complete avoidance or conservative dosing of 2 g or less per day
29
Who is at increased risk for APAP induced hepatotoxicity
- liver disease
- concurrent use of other potentially hepatic drug
- poor nutritional intake
- consumption of 3+ alcoholic drinks per day
30
What is considered one alcoholic drink
12 oz beer
5 oz wine
1.5 oz of 80 proof liquor
31
Proof (alcohol)
The measure of alcohol content in a beverage
TWICE THE % ABV
31
Commercial formulation of acetaminophen
Rectal suppositories
Liquid
Liquid gels
Tablets
Powder packs that dissolve in liquid
32
Types of tablets in APAP
Caplets
Chewables
33
Dosing of IR APAP for adults
325 mg tabs
3250 mg per day OTC
34
Dosing of extra strength APAP for adults
500 mg
3000 mg per day OTC
35
APAP pediatric dosing
10-15 mg/kg/dose q4-6h PRN
35
Dosing of ER APAP for adults
650 mg
3900 mg per day OTC
36
Max adult APAP daily dose
4000 mg per day under HCP supervision
37
Max pediatric APAP dose
480 mg/dose, up to 5 doses
OR
75 mg/kg/day
37
How much APAP should you not exceed for pediatrics per day
2400 mg/day
38
FDA recommendations for APAP dosing
The lower max daily limits and that pediatric ORAL dosage forms be limited to a single strength (160 mg)
39
Stage 1 APAP toxicity
Nausea/vomiting
Drowsiness
Confusion
Abdominal pain
EARLY SIGNS AND SYMPTOMS MIGHT BE DELAYED
40
Stage 2 APAP toxicity
- 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
41
Stage 3 APAP toxicity
- develops after 3-4 days and progresses to liver failure without treatment
- metabolic acidosis, encephalopathy, cerebral edema, renal failure
- may have continuous GI symptoms
42
Stage 4 APAP toxicity
- begins 4 days after ingestion
- can last weeks
- hepatic damage is reversible for the majority of cases
- some may need liver transplant
43
Antidote for APAP poisoning
N-acetylcysteine
44
What is the need for using N-acetylcysteine determined by
Rumack-Matthew nomogram
45
Warfarin-APAP interaction
- increased bleeding risk
- regular use of APAP while pt on warfarin should be discouraged
45
Clinically important APAP drug interactions
Alcohol
Warfarin
46
Severe liver damage may occur if…
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
47
Limit of APAP in opioid rx combo products
325 mg/dosage unit
47
Analgesic of choice for warfarin patients
APAP
48
NSAIDs
Ibuprofen (motrin, advil)
Naproxen (aleve)
49
Acetylated salicylate NSAID
Aspirin
50
Non-acetylated salicylate NSAID
Magnesium salicylate
51
OTC naproxen strength
220 mg
51
OTC ibuprofen strength
200 mg tabs
52
MOA of NSAIDs (ibu + naproxen)
Central AND peripheral inhibition of COX, which then inhibits prostaglandins synthesis
53
Indication of NSAIDs
Fever
Mild-moderate non-visceral pain
54
NSAIDs metabolism/excretion
Metabolized by liver
Eliminated by kidneys
54
Onset of NSAID analgesic activity
30 min
55
Duration of analgesic activity for ibuprofen
6-8 hours
55
NSAIDs absorption
Well absorbed from the GI tract
56
Duration of analgesic activity for naproxen
12 hours
57
Warnings for NSAIDs
CHR may be exacerbated by NSAID use
Increased risk of renal toxicity in certain populations
58
Risk factors for renal toxicity in ibuprofen use
Advanced age
HTN
Diabetes mellitus
Using diuretics
Atherosclerotic CV disease
(Ass Holes Don’t Usually Ask)
59
Contraindications for NSAIDs
Contraindicated for perioperative pain after CABG surgery
60
Common adverse reactions w/ NSAIDs
Dyspepsia
Epigastric pain
Nausea
Anorexia
Dizziness
GI upset
Heartburn
Nervousness
Fatigue
(Don’t Eat Nsaids All Day, Gonna Have No Fun)
61
Uncommon adverse reactions w/ NSAIDs
Rash
Pruritis
Photosensitivity
Fluid retention/edema
62
Serious and rare adverse reactions w/ NSAIDs
GI ulceration
Perforation
Bleeding
63
Risk factors for serious adverse reactions w/ NSAIDs
- 60+
- Previous ulcer disease
- Concurrent use of anticoagulant (including aspirin)
- High doses
- Long treatment duration
- 3+ alcoholic drinks/day
64
What is a serious problem that NSAIDs can cause
Premature closing of ductus arteriosus, which may lead to heart failure in the infant
65
What do the adverse reactions of NSAIDs tell us
- 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
OTC commercial formulations of ibuprofen
Liquid
Tablet/caplet
Capsule
Liquid gels
67
OTC commercial formulations of naproxen
Capsules
Tablets/caplets
Gel caps
Liquid gels
67
AleveX
Available as topical lotions and sprays OTC
Does NOT contain naproxen
67
Motrin
Topical gel available
Does NOT contain ibuprofen
68
Adult ibuprofen dosing
200 - 400 mg q6-8h PRN
69
Daily max of ibuprofen OTC
1.2 g per day
69
Pediatric OTC ibuprofen dosing
5-10 mg/kg/dose q6-8h PRN
70
Pediatric OTC ibuprofen daily max
300 mg per dose, up to 4 doses
OR
40 mg/kg/day
71
Pediatric OTC ibuprofen dosing should not exceed
1200 mg/day
72
Naproxen OTC dosing
200 mg (220 mg naproxen sodium) q8-12h
73
Max OTC naproxen dosing
3 tablets in 24 hours
74
How much naproxen sodium is equal to regular 200 mg naproxen
220 mg naproxen sodium
74
How should you take ibuprofen liquid
Take with food or milk to help with stomach upset
74
How should you take ibuprofen tablets
Take with a full glass of water
75
What should happen w/ ibuprofen suspensions
Shake well
76
Why is naproxen sometimes preferred over ibuprofen
Naproxen has less frequent dosing (BID)
A good option for people struggling with adherence
76
Ibuprofen toxicity
- overdose rarely fatal
- minimal signs and symptoms of toxicity
77
GI manifestations of ibuprofen toxicity
Nausea
Vomiting
Diarrhea
Abdominal pain
78
Most serious effects of large naproxen overdose
Renal; failure
Neurological toxicity
Acid base changes
79
Drug interactions of ibuprofen
Alcohol (increased GI bleed risk)
Increased bleeding risk when taken w/ other agents that increase bleeding risk
80
Drug interactions of naproxen
Increased lithium and methotrexate levels when taken with NSAIDs
Multiple NSAIDs should not be used together
81
When can multiple NSAIDs be used together
NSAIDs used with low dose aspirin for cardio protection
82
Signs and symptoms of upper GI bleed
Hematemesis (vomiting bright red blood)
Coffee ground emesis
Melena (dark, tarry stool)
83
Signs and symptoms of lower GI bleed
Hematochezia (right red/fresh blood in feces)
84
Signs and symptoms of nonspecific GI bleed
Epigastric pain
Anemia
Syncope
Fatigue
85
Trade names for aspirin
Vazalore
St Joseph’s
Ecotrin
Bayer
85
Who is at increased risk for upper GI bleed
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
Indication of salicylate NSAIDs (aspirin)
Analgesic
Antipyretic
87
MOA for aspirin
Inhibits COX-1 and COX-2, which inhibits prostaglandin synthesis
Primary peripheral action
87
Aspirin is hydrolyzed to _______
Salicylic acid
88
Absorption of aspirin
Well absorbed from GI tract
89
Rectal absorption of aspirin
Slow and unreliable
89
Onset of aspirin analgesic activity
30 min
90
What medications can be used in patients w/ an aspirin intolerance
APAP and methyl salicylate
90
Warnings for aspirin use
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
Duration of aspirin analgesic activity
About 4-6 hours
91
What is the effect of patients with history of gout taking aspirin
Aspirin may cause reemergence of gout if used 2+ days
92
Asthma sensitivity and aspirin use
Not really allowed
10% of people with asthma have aspirin sensitivity
93
Two types of serious intolerance to aspirin
Cutaneous
Respiratory
94
Cutaneous intolerance to aspirin reactions
Edema
Angioedema
94
Respiratory intolerance to aspirin reactions
Bronchospasm
Laryngospasm
Rhinorrhea
95
Contraindications for aspirin
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
Common adverse reactions to aspirin
Upset stomach (dyspepsia)
Heartburn
Bleeding
Nausea
97
Severe adverse reactions to aspirin
Stevens Johnson syndrome rash
Toxic epidermal necrolysis rash
GI ulceration and bleeding
97
When should pregnant people avoid using aspirin
Avoid in third trimester due to fetal harm
98
Commercial formulations of aspirin
Tablets (regular and chewable)
Liquid filled capsules (vazalore)
99
Which aspirin brand is formulated as liquid filled capsules
Vazalore
100
Commercial strengths of aspirin
81 mg
300 mg
325 mg
500 mg
101
Analgesic dosing for aspirin
325-650 mg q4-6h
102
Cardioprotective dosing for aspirin
81-162 mg once daily
103
Signs and symptoms of salicylism toxicity
Occasional diarrhea
Lassitude
Dizziness
Drowsiness
Hyperventilation
Confusion
Nausea and vomiting
Headache
Sweating and thirst
Tinnitus
(OLD Damn Hags Can Never Have Salicylism Toxicity)
103
Salicylism toxicity in aspirin use
Chronic toxic blood levels for at least 2 days
104
Salicylate intoxication due to aspirin
Higher blood levels than salicylism
Clinical manifestations depend on blood concentration
104
How is salicylate intoxication characterized
Mild
Moderate
Severe
105
Signs and symptoms of salicylate intoxication
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
Important drug interactions in aspirin
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
Salicylates are known to be
Ototoxic
107
Aspirin toxicity reactions in children
High fever
Serious hypoglycemia
108
Antidote for aspirin toxicity given in the ER setting
Gastric lavage or activated charcoal
109
What does taking an enteric coating with food produce
Longer absorption time due to prolonged gastric emptying time
109
When should you stop use of aspirin
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
If the stomach acid is low (due to acid-suppressing meds like a PPI), what might happen to a product with an enteric coating
Product may dissolve in the stomach, which can cause stomach irritation
109
What can the use of aspirin produce
Positive result on fecal occult blood testing
110
Does enteric coating decrease the risk of GI bleed
NO
It is advertised as safer, but isn’t actually
110
When should you NOT use an enteric coated product
If you are in need of rapid pain relief
111
Buffered dosage forms
Tablet and effervescent forms
112
What is the point of a buffered dosage form
Combines an antacid w/ aspirin to absorb more rapidly
113
Common buffer dosage forms
Calcium carbonate
Aluminum hydroxide
Magnesium hydroxide
Sodium bicarbonate
(CAMS)
114
Effervescent tablets
Use the sodium bicarb and may contain large amounts of sodium
Watch for patients on sodium reduced diets
115
*What should you be aware of before recommending effervescent tablets to a patient
Make sure they are not on a sodium reduced diet because they often have a very high sodium content
116
Do buffered dosage forms decrease the risk of GI bleed
NO
Marketed as safer but isn’t actually
117
What does the progressive neurologic damage in Reye’s syndrome START with? What does it progress to?
Starts w/ lethargy
Progresses to:
- delirium
- confusion
- seizures
117
What is Reye’s syndrome
- progressive neurologic damage
- fatty liver encephalopathy
- hypoglycemia
- mortality rate around 50%
118
Reye’s syndrome happens in what patient population
Almost exclusively in children and teenagers
119
Cause of Reye’s syndrome
Cause is technically unknown
Using salicylate to treat a viral illness such as flu and chicken pox is associated w/ it
120
What does aspirin do to platelet function
Irreversibly inhibits platelet function
Meaning the inhibition continues for the duration of the platelet’s life
121
Salicylate NSAID legal requirements
GI risks
Cardiovascular risks
Contraindicated w/ CABG
Alcohol
Reye’s syndrome
122
Motrin dual action combination products
Acetaminophen and ibuprofen
123
Advil dual action combination products
Acetaminophen and ibuprofen
124
Bayer back and body combination products
Aspirin and caffeine
125
Excedrin combination products
Acetaminophen
Aspirin
Caffeine
125
BC combination products
Aspirin and caffeine
126
Max strength BC combination products
Acetaminophen
Aspirin
Caffeine
127
OTC analgesic use in the elderly population
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
Aspirin use in pregnancy
No aspirin in pregnancy, ESPECIALLY in the 3rd trimester
127
Which OTC analgesics can be used in children 2+
Acetaminophen
Ibuprofen
128
Which analgesics can be used in children 12+
Acetaminophen
Ibuprofen
Naproxen
128
NSAID use in pregnancy
NSAIDs are not shown to be teratogenic
Contraindicated in 3rd trimester
129
Acetaminophen use in pregnancy
Crosses the placenta but is considered safe for pregnancy
129
Which analgesic is preferred in breastfeeding patients
Ibuprofen
It is considered the safest because of the very low concentration in breastmilk and lack of ill effect in infants
130
Acetaminophen use in infants
Crosses into breastmilk at a low ration
**may cause rash in infants that subsides after discontinuation
131
Naproxen use in breastfeeding
DO NOT USE
132
Aspirin use in breastfeeding
DO NOT USE
133
Renal impairment
Caution w/ salicylates and other NSAIDs
Ask renal doctor to recommend
134
Hepatic impairment
Caution to be used w/ acetaminophen
Prolonged use/high doses must be avoided
135
Aspirin allergy
15% tartrazine cross reactivity
This is because tartrazine is a yellow dye #5
136
If a person is allergic to aspirin, what is their cross reactivity with APAP, ibuprofen, and naproxen
7% cross reactivity w/ APAP
98% cross reactivity w/ ibuprofen
100% cross reactivity w/ naproxen
137
Dosing preference
- BID dosing w/ naproxen
- ER APAP dosed q8h
