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Therapeutics > Exam 5 lecture 5 > Flashcards

Exam 5 lecture 5 Flashcards

1
Q

What questions would you ask to subjectively assess a pt pain

A

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

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2
Q

objective information to assess pain

A

Behavioral changes
Physiological- pupil dilation, sweating, HR)

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3
Q

What would you use to assess pain

A

Verbal
Numeric
visual
wong baker

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4
Q

Classify pain based on duration

A

Acute- <3 months
Chronic- >3 months

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5
Q

What are the goals of therapy in treating non malignant pain

A

Correct -underlying issue
minimize- pain and sx
Improve-QOL
Limit- side effects

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6
Q

Non pcol therapies to help with non malignant pain

A

exercise
acupuncture
heat or ice
massage
physical manipulation

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7
Q

What is the stepwise treatment approach in treating non malignant pain

A

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

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8
Q

What are the non opioids to use in Step 1 non opioid therapy

A

Acetaminophen
NSAIDs

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9
Q

What are the adjuvant therapies used along with non opioid anelgesics

A

gabapentinoids
SSRIs
TCAs
Skeletal muscle relaxant
Antiepileptic
topical agent

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10
Q

Review brand/generic name of acetaminophen

A

Tylenol

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11
Q

Dosage forms and dosing of Acetaminophen/tylenol

A

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

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12
Q

Side effects of Acetaminophen (tylenol)

A

Hepatotoxicity

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13
Q

clinical pearls for acetaminophen (tylenol)

A

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

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14
Q

NSAIDs side effects

A

Side effects
 GI bleeding (black box warning)
 Nephrotoxicity
 Fluid retention
 Increase CV events (black box warning

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15
Q

NSAIDs clinical pearls

A

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

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16
Q

Aspirin (Bayer) available formulations

A

Available formulations
 Chewable tablet
 Tablet
 EC tablet
 Capsule
 ER capsule
 Suppository

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17
Q

Aspirin (Bayer) recommended dosing

A

 Adults: 325mg-1000mg PO q4-6h PRN (max 4g/day)
 Pediatrics: Avoid (Reye’s syndrome)

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18
Q

Aspirin (Bayer) clinical pearls

A

Avoid using for pain in patients taking blood
thinners or antiplatelets

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19
Q

What is Reyes syndrome and what is it caused by?

A

swelling in brain or liver in children, associated with children taking aspirin while they have a viral infection

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20
Q

Ibuprofen available formulations

A

Capsule
 Tablet (regular strength = 200mg)
 Chewable tablet
 Suspension
 IV solution

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21
Q

Ibuprofen brand name

A

Motrin, advil

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22
Q

Ibuprofen dosing? Max?

A

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)

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23
Q

Diclofenac brand name

A

voltaren

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24
Q

Diclofenac available formulations

A

 Capsule
 Tablet
 IV solution
 Suppository
 Topical gel (Voltaren 1% gel)
 Topical solution
 Ophthalmic solution
 Patch

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25
Q

Diclofenac dosing

A

Adults: 50mg PO q8h or 2-4 g applied topically 4
times/day

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26
Q

Diclofenac clinical pearls

A

Minimal systemic side effects with topical gel

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27
Q

Naproxen generic

A

Alleve, Naprosyn

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28
Q

Naproxen available formulations

A

 Capsule
 Tablet
 DR/ER tablet
 Suspension

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29
Q

Recommended dosing of Naproxen (max dose too)

A

Adults: 220-500mg PO q6-12h (max 1000mg/day

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30
Q

Ketorolac brand name

A

Toradol

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31
Q

Ketorolac available formulations

A

 Tablet
 IV/IM solution
 Nasal spray
 Ophthalmic solution

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32
Q

Ketorolac (toradol) dosing

A

Adults: 15-30mg IV/IV q6h prn or 10mg PO q6h prn
Pediatrics: 0.5mg/kg/dose IM/IV q6h prn

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33
Q

Ketorolac (toradol) clinical pearls

A

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

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34
Q

Celecoxib available formulations

A

Capsule
Oral solution (less common)

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35
Q

Recommended dosing of celecoxib (toradol)

A

Adults: 200mg PO BID

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36
Q

Which drugs have non-oral for pts that can not take oral meds

A

Aspirin- suppository
Ibuprofen IV
Diclofenac- IV, patch, gel, suppository
Ketorolac- IV solution

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37
Q

Oral solution for kids

A

Tylenol
Motrin
Aleve (not used commonly, labe says >12 years old)

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38
Q

What are the gabapentinoid drugs

A

Gabapentin and pregabalin

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39
Q

Brand name for gabapentin and pregabalin

A

Gabapentin- neurontin
Pregabalin- lyrica

40
Q

Uses of the gabapentinoids

A

Fibromyalgia
Neuropathies
Post-operative pain

41
Q

Available formulations for Gabapentin/oregabalin

A

Tablets/capsule
ER tablet
Liquid solution

42
Q

Recommended dosing for gabapentin/pregabalin (include max)

A

Gabapentin (Neurontin): 100-300mg PO TID (max 3600mg/day)
Pregabalin (Lyrica): 75mg PO BID (max 600mg/day)

43
Q

side effects of gabapentin/pregabalin

A

Sedation, dizziness, peripheral edema

44
Q

clinical pearls of gabapentin/pregabalin

A

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

45
Q

What are SNRIs used in non malignant pain

A

Duloxetine and venlafaxine

46
Q

What are the brand names of venlafaxine and Duloxetine

A

venlafaxine- effexor
Duloxetine- cymbalta

47
Q

Uses of venlafaxine and duloxetine

A

Fibromyalgia
Neuropathy

48
Q

available formulations of venlafaxine/duloxetine

A

Capsule/tablet
ER capsule/ER tablet

49
Q

recommended dosing of venlafaxine and duloxetine (include max)

A

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)

50
Q

Side effect of duloxetine/venlafaxine

A

Nausea, headache, hypertension, sedation,
weakness

51
Q

clinical pearls for venlafaxine and duloxetine

A

Start low dose and titrate up to minimize side
effects

Renally dose adjust venlafaxine and avoid
duloxetine for CrCl < 30 mL/mi

52
Q

What are the TCAs used for adj therapy?

A

Amitriptyline
Nortriptyline

53
Q

Amitriptyline and nortriptyline brand names

A

Amitriptyline- Elavil
Nortriptyline- Pamelor

54
Q

available formulations for TCAs

A

Tablet (amitriptyline)
Capsule (nortriptyline)
Oral solution (nortriptyline)

55
Q

Recommended dosing for TCAs

A

Amitriptyline or nortriptyline: 10mg PO QHS (max
150mg/day

56
Q

Side effects of TCAs

A

Anticholinergic

57
Q

clinical pearls of TCAs

A

Last line option for neuropathy and fibromyalgia
due to side effects

58
Q

What are the muscle relaxants used in non malignant pain

A

cyclobenzaprine
baclofen
Methocarbimol
carisoprodol
Tizanidine

59
Q

Recommended dosing for muscle relaxants

A

 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)

60
Q

side effects and clinical pearls of mucscle relaxants

A

Sedation/ drowsiness, dizziness, dry mouth, vision
changes

Clinical pearls
 Short term use (<3 weeks)
 Carisoprodol is schedule IV due to abuse potential

61
Q

Carbamazepine brand name

61
Q

What is an anticonvulsant that is used in non malignant pain treatment

A

carbamazepine

61
Q

Carbamazepine dosing (include max)

A

 200mg-400mg PO daily in 2-4 divided doses (max
1200mg/day)

62
Q

clinical pears of carbamazepine

A

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

63
Q

Lidocaine available formulations

A

Patch
inj
topical

64
Q

recommended dosing of lidocaine

A

Apply 1 patch to affected area and take it off after 12 hours

65
Q

Side effects of lidocaine

A

Hypotension, arrythmia (minimal risk with patch)

66
Q

Clinical pearls of lidocaine

A

Tachyphylaxis with continuous use
12 hour break between patches
Local effect- apply to site of pain

67
Q

capsacin use

A

Muscle/joint pain
Neuropathic pain

68
Q

Available formulations for capsacin

A

ream, gel, liquid, lotion: Apply 3-4 times per day
 Patch: Apply 1 patch to affected area daily and
remove 8 hour later

69
Q

side effects for capsacin

A

Skin irritation and pain

70
Q

clinical pearls of capsacin

A

Do not get medicine into eyes (burning)
 Wash hands after applying
 Some formulations available OTC

71
Q

consideration of use of non COX 2 selective NSAIDs (including Aspirin >325 mg/day) guide for patients older than 65

A

Non cox 2 selective NSAIDs increase risk of GI bleeding and peptic ulcer disease. Avoid chronic use unless no alternative

72
Q

What meds should patients older than 65 take if they are taking non cox 2 selective drugs

A

pt should be on a PPI.

73
Q

Indomethacin and ketorolac use in pts over 65

A

Increase risk for GI bleeding
avoid it
(indomethacin has most side effects )

74
Q

What are the skeletal muscle relaxants to avoid in patients older than 65

A

Carisoprodol
Cyclobenzaprine
Methocarbamol

AVOID

75
Q

What skeletal muscle relaxants should be used in patients older than 65

A

Baclofen
Tizanidine

76
Q

What is the recommendation for SNRIs, TCA, and carbamazepine in patients older than 65. Why?

A

Use with caution

May exacerbate or cause SIADH or hyponatremia

monitor sodium closely

77
Q

Recommendation of combo Opioid and BZD use in pts older than 65

A

Avoid, may cause OD

78
Q

Recommendation of combo Opioids and Gabapntin/pregabalin

A

Avoid (except when transitioning from opioid to gabapentinoid or using gabapentinoid to reduce opioid dose)

79
Q

Recommendation of anticholinergic + anticholinergic in pts older than 65

A

(TCA or muscle relaxant)

Avoid

80
Q

Avoid using 3 or more of which medictaions in patients older than 65

A

Antiepileptics (including
gabapentinoids)
Antidepressants (TCAs, SSRIs,
and SNRIs)
Antipsychotics
Benzodiazepines
Z drugs
Opioids
Skeletal Muscle Relaxants

81
Q

Exam- Which pain meds to use in elderly to minimize side effects

A

Acetaminophen, topical agents (lidocaine, diclofenac), SNRI, Gabapentinoids

82
Q

When do we stop duloxetine

A

If CrCl<30

83
Q

Can we continue acetaminophen in kidney dysfunction

84
Q

What can we use to replace duloxetine if CRCL<30

A

Venlafaxine

85
Q

Ibuprofen dosing in peds

A

100mg/5mL- 5mL q6h PRN

86
Q

Acetaminophen dosing in peds

A

160mg/5mL- 7.5mL
q6H PRN

87
Q

Gabapentin dosing in peds

A

Gabapentin 300mg daily

88
Q

counseling point for ibuprofen in peds

A

Take with food
use actual measuring device (not tbsp, tsp)

89
Q

Should we give an elderly patient ibuprofen or aspirin?

A

No. They are on beers. Give acetaminophen insead

90
Q

Acetaminophen dosing in elderly

A

325 mg q4h PRN

91
Q

What is an opioid antagonist

92
Q

What is a weak agonist for opioid receptors

A

Codeine, tramadol

93
Q

tx of opioid OD

A

Naloxone in hospital IV
community Nasal

94
Q

tx of opioid withdrawal

Therapeutics (38 decks)

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