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701 > Exam 4: PAIN > Flashcards

Exam 4: PAIN Flashcards

1
Q

Neuropathic pain

A

pain caused by a lesion or disease of the somatosensory nervous system; damage to nerves

  • increased nerve cell firing
  • decreased inhibition of neuronal actvity d/t deafferenation and/or sensitization
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2
Q

Steps in noiciceptive pain

A
  1. stimulation
  2. transmission
  3. perception
  4. modulation
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3
Q

Myelinated vs. unmyelinated transmission

A
  • myelinated - fast sharp pain
  • unmyelinated - dull ache
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4
Q

Endogenous analgesic system

A

The opiate system
* NDMA receptors decrease the effects of opioates therefore, NDMA antags can enhance the actions of endogenous opiates

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5
Q

Role of NE and 5-HT neurons in pain

A

Inhibit pain transmission?

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6
Q

Spontaneous pain transmission

A
  • contiuous - burning, throbbing, aching, shooting
  • intermittent (episodic, paroxysmal) - shooting, stabbing, or electric shock-like
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7
Q

Hyperalgesia

A

increased pain form a stimulus that normally provokes pain

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8
Q

Allodynia

A

Pain d/t stimulus that does not normally provoke pain

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9
Q

Types of neuropathic pain

A
  1. spontaneous transmission (continuous and intermittent)
  2. hyperalgesia
  3. allodynia
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10
Q

Advantages of using TCAs for pain

A
  • has a lot of data supporting use
  • QD dosing
  • conmittent insomnia and depression treatment
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11
Q

Disadvantages of using TCAs for paiin

A
  • delayed onset
  • anticholinergic
  • cardiotoxic
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12
Q

General TCA dosing for pain

A
  • Start: 25mg QHS
  • MDD: 150mg/day
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13
Q

Advantages of using SNRIs for pain

A
  • duloxetine FDA approved for PDN ad fibromylagia
  • conmittant depression treatment
  • favorable side effect profile
  • milnacipran: can improve fatigue
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14
Q

PDN

A

painful diabetic neuropathy

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15
Q

PHN

A

post-herpetic neuralgia

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16
Q

LBP

q

A

lo back pain

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17
Q

Disadvantages of using SNRIs for pain

A
  • Risk of serotonin syndrome with interacting meds
  • Duloxetine: CI in hepatic impairment and ESRD (CrCl <30)
  • Milnacipran: BID dosing, HTN ADR
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18
Q

SNRI dosing for pain

A

duloxetine
* start: 30mg QD
* MDD: 60mg BID

venlafaxine
* start: 37.5mg QD or BID
* MDD: 225mg TDD

milnacipran
* start: 12.5mg QD
* titrate over 1 week to 50mg BID
* MDD: 100mg BID

19
Q

milacipran MOA

A

SNRI
* 3:1 NE:serotonin activity
* NMDA receptor binding
* lacks histaminic and muscarinic activity

20
Q

Gabapentinoids MOA

A

Modulate hyperexcited neurons

21
Q

Advantages of using gabapentin for pain

A
  • low incidence of DDI and ADR
  • FDA approved for PHN
22
Q

Disadvantages of using gabapentin for pain

A
  • mild CNS depression
  • significant tox

Renally dose adjusted:
* CrCl 30-59 MDD: 700mg BID
* CrCl 15-29 MDD: 700mg QD
* CrCl 15 MDD: 300mg QD
* CrCl <15 MDD: proportinal to CrCl (if CrCl = 7.5 pt gets half of dose for CrCl 15)

23
Q

Gabapentin formulations and dosing frequency

A
  • PO capsule, tab, solution: TID
  • PO tab ER: QD with evening meal
  • PO enacarbil tab ER: BID
24
Q

Advantages of using pregabalin for pain

A
  • low incidence of DDI and ADR
  • conmittant anxiety treatment
  • FDA indicated for PDN, PHN, and fibromyalgia
25
Q

Disadvantages of using pregabalin for pain

A
  • DEA schedule V - dependency and euphoria
  • mild CNS depression
  • significant tox
  • renal insufficiency
26
Q

Pregabalin dosing for pain

A
  • start: 150mg TDD taken BID or TID
  • titrate every 3-7 days
  • MDD: 600mg TDD
27
Q

Advantages of using tramadol for pain

A
  • less respiratory depression than opiates
  • lower abuse potential than opiates
  • treats neuropathic pain: inhibit reuptake of NE and 5-HT in CNS
28
Q

Disadvantages of using tramadol for pain

A

DDI
* CBZ
* quinidine
* TCA
* SSRI

ADR
* dizziness
* GI upset
* constipation
* seizure risk

29
Q

Tapentadol indication and MOA

A

neuropathic pain associated with diabetic peripheral neuropathy; DEA schedule II

MOA
* mu agonist
* NE reuptake inhibition
* weak anticholinergic effects

30
Q

Tapentadol dosing

A

Q4-6 hrs

available as 50, 75, 100mg

31
Q

Capsaicin MOA for pain

A

deplete and prevent re-accumulation of substance P in peripheral sensory neurons

FDA approved

32
Q

Important counseling points for Qutenza capsaicin patches

A
  • pre-treat with local anesthetic
  • use up to 4 patches per application
  • leave patches on for 60 miites
  • do NOT use more than Q3 mo.
  • patch strength is 8% (vs. normal OTC which is .025% or .25%
33
Q

Lidocaine indications

A

PHN and topical anesthesia -> often used off label for pain

Quick onset of 5-10 min :)

34
Q

1st line treatment for neuropathic pain

A
  • TCA
  • SNRI
  • gabapentinoids
  • topicals
35
Q

2nd line treatment for neuropathic pain and when do we use 2nd line

A

exacerbation or inadequate response to first line
* tramadol
* combo of 1st line therapies

36
Q

3rd line treatment for neuropathic pain and when do we use 3rd line

A

inadequate use response to 2nd line
* specialist referral first!
* SSRI/NMDA antag
* interventional therapies

37
Q

4th line treatment for neuropathic pain and when do we use 4th line

A

inadequate response to 3rd line, 6+ months of neuropathic pain
* neuromodulation

38
Q

5th line treatment for neuropathic pain and when do we use 5th line

A

inadequate response to 4th line
* 4-6 week trial of low-dose opiates with regular 3 mo. reviews

39
Q

Is all diabetic neuropathy painful?

A

No

40
Q

Painful diabetic neuropathy mechanism

A
  • damage to peripheral nerves - hyperexcitability, spontaneous nerve impuses
  • abnormal electrical connections
  • coupling of sympathetic and afferent neurons and abnormal release of substance P from A fibers
  • persistent nervve stimulation activates NDMA receptors
41
Q

treatment for painful diabetic neuropathy

A
  • gabapentinoids
  • TCA
  • SNRI
  • sodium channel blockers (TEST QUESTION)

consider adding capsacin or switching between these classes before moving on to opiates

42
Q

treatment for post-herpetic neuralgia

A
  • TCAs
  • antiepileptics (gabapentinoids, divalproex)
  • tramadol
  • lidocaine (best for focal)
  • capsaicin
  • opiates if all is fails
43
Q

fibromyalgia

A
  • enhanced sensitivity to stimuli (heat and cold)
  • constant dull ache in all 4 quadrants
  • often accompanied by fatigue and sleep disturbances
44
Q

treatment for fibromyalgia

A
  • CBT where appropriate
  • duloxetine
  • pregabalin
  • tramadol
  • milnaciprin is FDA approved but not really on guidelines

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