Exam 5 lecture 5 Flashcards by Matti Daniel

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

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objective information to assess pain

Behavioral changes
Physiological- pupil dilation, sweating, HR)

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What would you use to assess pain

Verbal
Numeric
visual
wong baker

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Classify pain based on duration

Acute- <3 months
Chronic- >3 months

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What are the goals of therapy in treating non malignant pain

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

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Non pcol therapies to help with non malignant pain

exercise
acupuncture
heat or ice
massage
physical manipulation

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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

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

Acetaminophen
NSAIDs

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What are the adjuvant therapies used along with non opioid anelgesics

gabapentinoids
SSRIs
TCAs
Skeletal muscle relaxant
Antiepileptic
topical agent

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Review brand/generic name of acetaminophen

Tylenol

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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

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Side effects of Acetaminophen (tylenol)

Hepatotoxicity

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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

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NSAIDs side effects

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

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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

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Aspirin (Bayer) available formulations

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

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Aspirin (Bayer) recommended dosing

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

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Aspirin (Bayer) clinical pearls

Avoid using for pain in patients taking blood
thinners or antiplatelets

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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

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Ibuprofen available formulations

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

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Ibuprofen brand name

Motrin, advil

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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)

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Diclofenac brand name

voltaren

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Diclofenac available formulations

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

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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