Exam 5 lecture 5 Flashcards
What questions would you ask to subjectively assess a pt pain
PQRSTU mnemonic
Palliative or percipitating factors
Quality of pain (burning, tingling)
Region of pain location
Severity
Tine related to nature of pain (how long)
U- impact to yoU
objective information to assess pain
Behavioral changes
Physiological- pupil dilation, sweating, HR)
What would you use to assess pain
Verbal
Numeric
visual
wong baker
Classify pain based on duration
Acute- <3 months
Chronic- >3 months
What are the goals of therapy in treating non malignant pain
Correct -underlying issue
minimize- pain and sx
Improve-QOL
Limit- side effects
Non pcol therapies to help with non malignant pain
exercise
acupuncture
heat or ice
massage
physical manipulation
What is the stepwise treatment approach in treating non malignant pain
Step 1- non opioid +/-adjunct therapy
Step 2- Opioid for mild/moderate pain + non opioid +/- adjuvant analgesic
Step 3- Opioid for moderate/severe pain, + non opioid, +/- adjuvant
step up if pain is increasing or persisting
Step down if pain is resolving or toxicity occurs
What are the non opioids to use in Step 1 non opioid therapy
Acetaminophen
NSAIDs
What are the adjuvant therapies used along with non opioid anelgesics
gabapentinoids
SSRIs
TCAs
Skeletal muscle relaxant
Antiepileptic
topical agent
Review brand/generic name of acetaminophen
Tylenol
Dosage forms and dosing of Acetaminophen/tylenol
Tablet (regular strength = 325mg, extra strength =
500mg, arthritis = 650mg ER tablet)
Capsule
Chewable tablet (80mg or 160mg)
Liquid/gel
IV solution
Suppository
Recommended dosing
Adults: 325 -1000mg PO Q4-6H PRN (max dose ≤3-4
g/day)
In liver disease, decrease max ≤2 g/day)
Pediatrics: 10-15 mg/kg PO Q4H PRN (max dose
75mg/kg/day or ≤3-4 g/day
Side effects of Acetaminophen (tylenol)
Hepatotoxicity
clinical pearls for acetaminophen (tylenol)
Gold standard for osteoarthritis due to fewer side
effects in geriatric patients than NSAIDs
Educate patients about max daily doses, including
combination products
Injection is expensive (often restricted use
NSAIDs side effects
Side effects
GI bleeding (black box warning)
Nephrotoxicity
Fluid retention
Increase CV events (black box warning
NSAIDs clinical pearls
Take with food
Caution use in geriatric patients due to increased
side effects (Beer’s list)
Avoid systemic NSAIDs in patients with cardiac
history (can use topical NSAIDs)
Avoid in severe liver disease or chronic kidney
disease
Aspirin (Bayer) available formulations
Available formulations
Chewable tablet
Tablet
EC tablet
Capsule
ER capsule
Suppository
Aspirin (Bayer) recommended dosing
Adults: 325mg-1000mg PO q4-6h PRN (max 4g/day)
Pediatrics: Avoid (Reye’s syndrome)
Aspirin (Bayer) clinical pearls
Avoid using for pain in patients taking blood
thinners or antiplatelets
What is Reyes syndrome and what is it caused by?
swelling in brain or liver in children, associated with children taking aspirin while they have a viral infection
Ibuprofen available formulations
Capsule
Tablet (regular strength = 200mg)
Chewable tablet
Suspension
IV solution
Ibuprofen brand name
Motrin, advil
Ibuprofen dosing? Max?
Recommended dosing
Adults: 200-800mg PO q6-8h PRN (max 3200mg/day)
Pediatrics (>6 months): 5-10 mg/kg PO Q4-6H PRN
(max 40mg/kg/day or 2400mg, whichever is less)
Diclofenac brand name
voltaren
Diclofenac available formulations
Capsule
Tablet
IV solution
Suppository
Topical gel (Voltaren 1% gel)
Topical solution
Ophthalmic solution
Patch
Diclofenac dosing
Adults: 50mg PO q8h or 2-4 g applied topically 4
times/day
Diclofenac clinical pearls
Minimal systemic side effects with topical gel
Naproxen generic
Alleve, Naprosyn
Naproxen available formulations
Capsule
Tablet
DR/ER tablet
Suspension
Recommended dosing of Naproxen (max dose too)
Adults: 220-500mg PO q6-12h (max 1000mg/day
Ketorolac brand name
Toradol
Ketorolac available formulations
Tablet
IV/IM solution
Nasal spray
Ophthalmic solution
Ketorolac (toradol) dosing
Adults: 15-30mg IV/IV q6h prn or 10mg PO q6h prn
Pediatrics: 0.5mg/kg/dose IM/IV q6h prn
Ketorolac (toradol) clinical pearls
Maximum duration is 5 days (parenteral + oral)
Increased risk of GI bleed when used longer
Oral dosing is intended a as a continuation of IM or
IV therapy
Celecoxib available formulations
Capsule
Oral solution (less common)
Recommended dosing of celecoxib (toradol)
Adults: 200mg PO BID
Which drugs have non-oral for pts that can not take oral meds
Aspirin- suppository
Ibuprofen IV
Diclofenac- IV, patch, gel, suppository
Ketorolac- IV solution
Oral solution for kids
Tylenol
Motrin
Aleve (not used commonly, labe says >12 years old)
What are the gabapentinoid drugs
Gabapentin and pregabalin
Brand name for gabapentin and pregabalin
Gabapentin- neurontin
Pregabalin- lyrica
Uses of the gabapentinoids
Fibromyalgia
Neuropathies
Post-operative pain
Available formulations for Gabapentin/oregabalin
Tablets/capsule
ER tablet
Liquid solution
Recommended dosing for gabapentin/pregabalin (include max)
Gabapentin (Neurontin): 100-300mg PO TID (max 3600mg/day)
Pregabalin (Lyrica): 75mg PO BID (max 600mg/day)
side effects of gabapentin/pregabalin
Sedation, dizziness, peripheral edema
clinical pearls of gabapentin/pregabalin
Renally dose adjusted
Titrate up dose to limit sedation
Use in combination to requirements of other analgesics
Pregabalin is a schedule V controlled substance, gabapentin is
unscheduled
What are SNRIs used in non malignant pain
Duloxetine and venlafaxine
What are the brand names of venlafaxine and Duloxetine
venlafaxine- effexor
Duloxetine- cymbalta
Uses of venlafaxine and duloxetine
Fibromyalgia
Neuropathy
available formulations of venlafaxine/duloxetine
Capsule/tablet
ER capsule/ER tablet
recommended dosing of venlafaxine and duloxetine (include max)
Venlafaxine: 37.5 – 75mg PO daily (max 225mg/day)
Duloxetine: 30mg PO daily x 1 week, then increase
to 60mg PO daily (max 60mg/day)
Side effect of duloxetine/venlafaxine
Nausea, headache, hypertension, sedation,
weakness
clinical pearls for venlafaxine and duloxetine
Start low dose and titrate up to minimize side
effects
Renally dose adjust venlafaxine and avoid
duloxetine for CrCl < 30 mL/mi
What are the TCAs used for adj therapy?
Amitriptyline
Nortriptyline
Amitriptyline and nortriptyline brand names
Amitriptyline- Elavil
Nortriptyline- Pamelor
available formulations for TCAs
Tablet (amitriptyline)
Capsule (nortriptyline)
Oral solution (nortriptyline)
Recommended dosing for TCAs
Amitriptyline or nortriptyline: 10mg PO QHS (max
150mg/day
Side effects of TCAs
Anticholinergic
clinical pearls of TCAs
Last line option for neuropathy and fibromyalgia
due to side effects
What are the muscle relaxants used in non malignant pain
cyclobenzaprine
baclofen
Methocarbimol
carisoprodol
Tizanidine
Recommended dosing for muscle relaxants
Cyclobenzaprine 5 mg PO TID (max 30mg/day)
Baclofen 5mg PO TID (max 80mg/day)
Carisoprodol 250-350 mg PO TID (max 1050mg/day)
Methocarbamol 1.5 g PO 3-4x/day (max 8g/day)
Tizanidine 2-4 mg PO q8-12h (max 24mg/day)
side effects and clinical pearls of mucscle relaxants
Sedation/ drowsiness, dizziness, dry mouth, vision
changes
Clinical pearls
Short term use (<3 weeks)
Carisoprodol is schedule IV due to abuse potential
Carbamazepine brand name
Tegretol
What is an anticonvulsant that is used in non malignant pain treatment
carbamazepine
Carbamazepine dosing (include max)
200mg-400mg PO daily in 2-4 divided doses (max
1200mg/day)
clinical pears of carbamazepine
Increased risk of hypersensitivity reaction in patient
with HLA-B*1502 allele
Autoinduction of hepatic enzymes (levels will fall
over first few weeks of use
Lidocaine available formulations
Patch
inj
topical
recommended dosing of lidocaine
Apply 1 patch to affected area and take it off after 12 hours
Side effects of lidocaine
Hypotension, arrythmia (minimal risk with patch)
Clinical pearls of lidocaine
Tachyphylaxis with continuous use
12 hour break between patches
Local effect- apply to site of pain
capsacin use
Muscle/joint pain
Neuropathic pain
Available formulations for capsacin
ream, gel, liquid, lotion: Apply 3-4 times per day
Patch: Apply 1 patch to affected area daily and
remove 8 hour later
side effects for capsacin
Skin irritation and pain
clinical pearls of capsacin
Do not get medicine into eyes (burning)
Wash hands after applying
Some formulations available OTC
consideration of use of non COX 2 selective NSAIDs (including Aspirin >325 mg/day) guide for patients older than 65
Non cox 2 selective NSAIDs increase risk of GI bleeding and peptic ulcer disease. Avoid chronic use unless no alternative
What meds should patients older than 65 take if they are taking non cox 2 selective drugs
pt should be on a PPI.
Indomethacin and ketorolac use in pts over 65
Increase risk for GI bleeding
avoid it
(indomethacin has most side effects )
What are the skeletal muscle relaxants to avoid in patients older than 65
Carisoprodol
Cyclobenzaprine
Methocarbamol
AVOID
What skeletal muscle relaxants should be used in patients older than 65
Baclofen
Tizanidine
What is the recommendation for SNRIs, TCA, and carbamazepine in patients older than 65. Why?
Use with caution
May exacerbate or cause SIADH or hyponatremia
monitor sodium closely
Recommendation of combo Opioid and BZD use in pts older than 65
Avoid, may cause OD
Recommendation of combo Opioids and Gabapntin/pregabalin
Avoid (except when transitioning from opioid to gabapentinoid or using gabapentinoid to reduce opioid dose)
Recommendation of anticholinergic + anticholinergic in pts older than 65
(TCA or muscle relaxant)
Avoid
Avoid using 3 or more of which medictaions in patients older than 65
Antiepileptics (including
gabapentinoids)
Antidepressants (TCAs, SSRIs,
and SNRIs)
Antipsychotics
Benzodiazepines
Z drugs
Opioids
Skeletal Muscle Relaxants
Exam- Which pain meds to use in elderly to minimize side effects
Acetaminophen, topical agents (lidocaine, diclofenac), SNRI, Gabapentinoids
When do we stop duloxetine
If CrCl<30
Can we continue acetaminophen in kidney dysfunction
Yes
What can we use to replace duloxetine if CRCL<30
Venlafaxine
Ibuprofen dosing in peds
100mg/5mL- 5mL q6h PRN
Acetaminophen dosing in peds
160mg/5mL- 7.5mL
q6H PRN
Gabapentin dosing in peds
Gabapentin 300mg daily
counseling point for ibuprofen in peds
Take with food
use actual measuring device (not tbsp, tsp)
Should we give an elderly patient ibuprofen or aspirin?
No. They are on beers. Give acetaminophen insead
Acetaminophen dosing in elderly
325 mg q4h PRN
What is an opioid antagonist
Naloxone
What is a weak agonist for opioid receptors
Codeine, tramadol
tx of opioid OD
Naloxone in hospital IV
community Nasal
tx of opioid withdrawal
Clonidine
