Exam 5 (final) - Rogers Flashcards
what the CDC practice guidelines include
outpts >18
acute pain (<1 month)
subacute pain (1-3 months)
chronic pain (>3 month)
what the CDC practice guidelines do NOT include
management of pain related to sickle cell disease
management of cancer related pain
palliative care
end of life care
WHO analgesic ladder
- non opioid +/- adjuvant analgesic
- opioid for mild-moderate pain +non opioid +/- adjuvant analgesic
- opioid for moderate-severe pain +non opioid +/- adjuvant analgesic
adjuvant options
gabapentanoids
SNRIs
TCAs
muscle relaxants
anti-epileptics
topical agents
pediatric acetaminophen dosing
10-15mg/kg po q4h prn
-max of 75mg/kg/day or 3-4g/day
pediatric dosing of aspirin
avoid (Reye’s Syndrome)
ibuprofen adult dosing
200-800mg PO q6-8h PRN
-max of 3200mg/day
ibuprofen pediatric dosing
> 6months: 5-10mg/kg po q4-6h prn
-max 40mg/kg/day or 2400mg/day, whichever is less
adult dosing diclofenac (Voltaren)
50mg po q8h
2-4g applied topically 4 times/day
naproxen (Aleve or Naprosyn) adult dosing
220-500mg po q6-12h
-max of 1000mg/day
ketorolac (Toradol) adult dosing
15-30mg IV/IM q6h prn
10mg po q6h prn
ketorolac (Toradol) peds dosing
0.5mg/kg/dose IV/IM q6h prn
max duration of ketorolac (Toradol)
5 days (parenteral and oral)
-reason is increased risk of GI bleed
celecoxib (Celebrex) adult dosing
200mg po BID
gabapentin (Neurontin) and pregabalin (Lyrica) uses
fibromyalgia
neuropathies
post-op pain
adult dosing for gabapentin (Neurontin) and pregabalin (Lyrica)
gaba: 100-300mg po TID
-max of 3600mg/day
pregaba: 75mg po BID
-max of 600mg/day
gabapentin (Neurontin) and pregabalin (Lyrica) side effects
sedation
dizziness
peripheral edema
gabapentin (Neurontin) and pregabalin (Lyrica) clinical pearls
titrate doses up to reduce sedation
use in combo with other analgesics to reduce sedation
renal dose adjustments
SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta) uses
fibromyalgia
neuropathy
SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta) dosing
V(E): 37.5-75mg po daily
-max of 225mg/day
D(C): 30mg po daily for 1 week, then increase to 60mg daily
-max of 60mg/day
SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta) side effects
N
HA
HTN
sedation
weakness
SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta) clinical pearls
start low and titrate up to minimize SE
renal dose adjustments:
-CrCl<30: avoid duloxetine and use low dose of venlafaxine
TCAs: amitriptyline (Elavil) and Nortriptyline (Pamelor) uses
fibromyalgia
neuropathy
migraine prophylaxis
TCAs: amitriptyline (Elavil) and Nortriptyline (Pamelor) dosage forms
tablet (ami)
capsule (nor)
oral solution (nor)
TCAs: amitriptyline (Elavil) and Nortriptyline (Pamelor) dosing
both: 10mg po QHS
-max of 150mg/day
TCAs: amitriptyline (Elavil) and Nortriptyline (Pamelor) side effects
anticholinergic SEs
sedation
TCAs: amitriptyline (Elavil) and Nortriptyline (Pamelor) clinical pearls
last line for fibromyalgia and neuropathy due to SE
muscle relaxants class includes:
cyclobenzaprine (Amrix, Fexmid)
baclofen (Lioresal)
methocarbamol (Robaxin)
carisoprodol (Soma)
tizanidine (Zanaflex)
muscle relaxants clinical pearls
short term use only (<3 weeks)
carisoprodol is C-IV due to abuse potential
muscle relaxants SE
sedation/drowsiness
dizziness
dry mouth
vision changes
anti-epileptics: carbamazepine (Tegretol) use
neuropathic pain
anti-epileptics: carbamazepine (Tegretol) clinical pearls
increased risk of hypersensitivity rxn if pt has HLA-B*1502 allele
auto-induction of hepatic enzymes (levels will fall over first few weeks of use)
lidocaine SE
hypotension
arrhythmia (less risk with patch)
lidocaine clinical pearls
tachyphylaxis with continued use
12hr break btwn patches
local effect - apply patch to site of pain
capsacian uses
muscle/joint pain
neuropathic pain
capsacian clinical pearls
do not get medicine into eyes (burns)
wash hands after applying
some forms are OTC
BEERs criteria considerations NSAIDs
-be cautious with NSAID use in those >75
–use PPI or misoprostol in combo with them
-avoid indomethacin and ketorolac
BEERs criteria considerations muscle relaxants
-avoid carisoprodol, cyclobenzaprine, and methocarbamol
BEERs criteria considerations SNRIs, TCAs, carbamazepine
-be cautious with SNRIs, TCAs, carbamazepine due to changes in Na+
BEERs criteria considerations opioids and benzo combo use
-avoid opioids and benzos combo therapy
BEERs criteria considerations opioids and gabapentanoids combo use
-avoid opioids and gabapentanoids
BEERs criteria considerations anticholinergics
-avoid anticholinergic with other anticholinergics and/or TCA or muscle relaxants
–decrease amount of anticholinergic effects pts is on in total
BEERs criteria considerations CNS acting drugs:
anti-epileptics (including gabapentanoids)
antidepressants (TCAs, SSRIs, SNRIs)
antipsychotics
benzos
Z drugs
opioids
muscle relaxants
avoid use of 3 or more to reduce risk of falls and fractures
tx of opioid withdrawal
clonidine
buprenorphine
methadone
opioids uses
acute and chronic pain
opioids SE
constipation
NV
itching
orthostatic hypotension
urinary retention
sedation
respiratory depression
opioids clinical pearls
consider starting stool softener and/or stimulant laxative
potential for tolerance, dependance or addiction
codeine (tylenol #3) clinical pearls
controlled substance (strengths determines what level)
metabolized by CYP2D6
-poor metabolizers get no effect from codeine
-ultra rapid metabolizers may experience OD, especially in children
-not recommended in breastfeeding mothers or children under 12
tramadol (Ultram-d/c, ConZip, Qdolo) clinical pearls
risk of serotonin syndrome with other serotonergic agents
renally dose adjusted
boxed warning: use of CYP3A4 inducers, inhibitors and 2D6 inhibitors with tramadol requires careful consideration of the effects on the parent drug and metabolite
morphine clinical pearls
itching more common than in other opioids
renally excreted and may accumulate in renal dysfxn
-avoid in AKI or ESRD
boxed warning: avoid alcohol while taking ER caps - leads to increased morphine levels and possible OD
hydromorphone (Dilaudid) clinical pearls
boxed warning: dosing errors when prescribing, dispensing and administering
-oral solution: confusion in mg and mL
-IV: do not confuse high potency solution (10mg/mL) with others (1, 2, or 4mg/mL)
hydrocodone +/- APAP clinical pearls
counsel pts on acetaminophen use and OD
boxed warning: use with CYP3A4 inhibitors may increase hydrocodone conc.
allergy cross reaction between opioids recommendations - natural opiates (morphine and codeine)
avoid in pts with allergy to other natural opiates and semi synthetic opioids
allergy cross reaction between opioids recommendations - semi synthetic opioids (hydrocodone, hydromphone, oxycodone, oxymorphone, buprenorphine)
avoid in pts with allergy to other semi synthetic opioids and natural opiates
allergy cross reaction between opioids recommendations - synthetic opioids (fentanyl, methadone, meperidine, tramadol)
can be used if pt has allergy to another synthetic opioid, semi synthetic opioid or natural opiate
oxycodone +/- APAP clinical pearls
APAP use and daily limit
boxed warning: use with CYP3A4 inhibitors may increase oxycodone conc.
fentanyl clinical pearls
monitor pts also on CYP3A4 inhibitors or inducers
can use in renal impairment
less HTN risk
besides injectable forms, fentanyl is only indicated for pts who are _______ _______, which means they have taken _____mg or more for at least __ week(s)
opioid tolerant, 60, 1
T/F: you can use the fentanyl transdermal patch dose and convert to oral morphine equivalent dose to choose an appropriate opioid option
F
T/F: you can use the oral morphine equivalent dose to calculate the fentanyl transdermal patch dose
T
fentanyl patch counseling
1 patch q72h
do not cut the patch or use it if torn or damaged
do not use over broken skin
avoid heating the patch (could lead to OD)
methadone clinical pearls
QTc prolongation
boxed warning: monitor pts receiving 3A4 inhibitors or inducers
long half life (8-59 hrs)
who to avoid meperidine in
avoid in elderly
avoid in renal impairment
caution in hepatic impairment
meperidine boxed warnings
boxed warning: monitor pts receiving 3A4 inhibitors or inducers
boxed warning: do not use within 14 days of MAOi
T/F: meperidine is a prodrug
T
list the opioids that may lower seizure threshold and may cause serotonin syndrome
TRAMADOL
oxycodone
fentanyl
methadone
meperidine
codeine
buprenorphine
opioid naive pts should be initiated on _____ (IR or ER) forms
IR
when should clinicians reevaluate benefits and risks of opioid use with pts
within 1-4 weeks of initiation
when should clinician help pt reduce/taper opioids
-if pt requests it
-no improvement in pain
-if pt is on 50MME+/day with out benefit or also on benzos
how to reduce/taper opioids
-decrease dose by 10% per month if pts have taken for more than a year
-decrease 10% per week if pts have taken for a shorter time (weeks-months)
-once lowest dose is reached, may alternate/extend days between doses (this is the point where they can be stopped)
2017 opioid prescribing limit states what?
physicians prescribing initial opioid to pt may not prescribe more than 7 days supply
-first Rx from that prescriber to that pt
exceptions:
-cancer
-medication assisted tx for SUD
-palliative care
-professional judgement
2019 inspect law requirements
-prescriber must check INSPECT each time they are prescribing an opioid or benzo to any pt
-must check INSPECT q90days
-no exceptions here
when taking acetaminophen and ibuprofen together, you should alternate them at an interval of q__h
3
pt education on pain
pain is normal while you are healing and recovering
goal is to manage it so you can do necessary tasks for yourself like:
-eat
-sleep
-walk
-breathe deeply
T/F: pts in hospital for acute pain can only have one prescription for one pain severity, not one for each level of severity (ex.-1-3, 4-6, or 7-10)
F, they can have one prescription for each of the severity levels
hospice - pain relief and air hunger
morphine IV or solution (20mg/mL) under tongue
-could use fentanyl or hydromorphone
hospice - anxiety/agitation
lorazepam IV or SL prn
hospice - N/V
ondansetron ODT
hospice - secretions
-atropine ophthalmic drops under tongue
-glycopyrrolate IV prn
-scopolamine patch
exception for using opioid and benzo together
hospice
