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Therapeutics > exam 5 lecture 6 > Flashcards

exam 5 lecture 6 Flashcards

1
Q

clinical pearls for opioids

A

Consider starting stool softener or laxative
Potential for tolerance, dependence, addiction
Schedule II

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2
Q

Side effects of opioids

A

Respiratory depression
Orthostatic Hypotension
Antitussive
constipation
N/V
Itching

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3
Q

Codein brand name

A

Tylenol #3

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4
Q

Codeine available formulations

A

Tabs and cough syrup

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5
Q

What is codeine metabolized into? What enzyme does that?

A

Codeine is turned into morpheine by 2D6

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6
Q

What can poor metabolizers expect from codeine? What can ultra rapid metabolizers expect from codeine

A

Poor- get no effect from codeine
Ultra rapid- Experience OD, resulting in death (especially children)

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7
Q

Tramadol brand name

A

ultram, Qdolo

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8
Q

Tramadol available formulations

A

Capsule
oral
solution
combo products

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9
Q

what warnings does tramadol have? Boxed warning?

A

warning- risk of serotonin syndrome when used with other substances

black box warning- Use of CYP 450 3A4 inducers, 3A4 inhibitors, and 2D6 inhibitors with tramadol requires careful consideration of the effects on the parent drug and metabolite

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10
Q

morphine available formulations

A

IV
long acting
suppository
inj
tab
capsule

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11
Q

What side effect is more prominent in morphine than other opioids

A

Itching

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12
Q

How is morphine eliminated

A

Renally excreted

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13
Q

When to avoid use of morhine

A

AKI or ESRD

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14
Q

boxed warning for morphine

A

avoid aclcohol use while taking ER capsules

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15
Q

Hydromorphone generic name

A

dilaudid

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16
Q

Hydromorphone available formulations

A

IR/ER
oral solution
injection
suppository

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17
Q

boxed warning for hydromorphone

A

dosing errors common in prescribing and dispensing. DO not confuse with high potency solution.

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18
Q

hydrocodone+acetaminophen drug naes

A

Norco
lortab
vicodin

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19
Q

Norco boxed warning

A

3A4 inhibitors may increase blood plasma levels of hydrocodone

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20
Q

Oxycodone available formulations

A

tabs
capsules
oral solutions

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21
Q

boxed warning for oxycodone

A

Use with CYP 3A4 inhibitors may
increase oxycodone plasma concentrations

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22
Q

fentanyl available formulations

A

Buccal tablet
sublingual liquid
lozenge’solution
patch

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23
Q

boxed warning for fentanyl

A

Monitor patients receiving CYP 3A4 inhibitors or inducers

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24
Q

can we use fentanyl in renal impairement

A

Monitor patients receiving CYP
3A4 inhibitors or inducers

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25
When can we use non injectable forms of fentanyl
When the patient are opioid tolerant
26
opioid tolerant is defined as
taking morphine 60mg per day (or equivalent) for at least 1 week
27
Can we convert from fentanyl to another product? Can we coonvert from another product to fentanyl?
We can only covert other products to fentanyl. Never fent to other products
28
Why do we never switch from transdermal fent to oral morphine
will cause OD
29
fentanyl patch counseling
1 patch x 3 days do not cut avoid hot things (sauna, hottub) not on broken skin showers ok
30
What is the use of methadone
last line for chronic pain opioid detox
31
boxed warning for methadone
US Boxed Warning: 1.Monitor patients receiving CYP 3A4 inhibitors or inducers 2.QTc prolongation check baseline ECG before tx
32
What are potential adverse effects of taking opioids
Serotonin activity could cause serotonin syndrome Seizure threshold is lowered
33
Which opioid is never used in pts with seizures
Tramadol
34
intial dosing for opioid naive pts
Codeine 15-60mg PO Q4H PRN Tramadol 25-50mg PO Q4-6H PRN Morphine 5-10mg PO Q4H PRN 2.5-5mg IV Q3-4H PRN Hydromorphone 2-4mg PO Q4-6H PRN 0.2-1mg IV Q2-3H PRN Hydrocodone 2.5-10mg PO Q4-6H PRN Oxycodone 5-15mg PO Q4-6H PRN Fentanyl 25-50mcg Q30-60min PRN
35
which opioid options would you recommend for someone who doesnt swallow
Morphine- IV Dilaudid- IV Duragesic- fentanyl IV solution Fentanyl patch- Not for opioid naive
36
Options for long acting opioids
Tramadol- ER capsure 24 H or ER tab Morphine- ER capsule 34 H or ER tab hydromorphone- ER tab hydrocodone- ER tab oxycodone- ER tab and capsule
37
Name the natural opiates
Morphine Codeine
38
Name the semi synthetic opiates
Hydromorphone oxycodone oxymorphine hydrocodone buprenorphine
39
Name the synthetic opiates
Fentanyl methadone meperidone tramadol
40
What is the allergic cross reaction present in opiates
Avoid natural and semi synthetic opiates due to allergy as there is cross reaction. no cross reaction in synthetic opioids
41
Do we switch to synthetic opioid for itching? Nausea? Anaphylaxis?
Not for itching and nausea, only for anaphylaxis
42
What are the scenarios we use different synthetic opiatesq
Fentanyl- IV for severe pain Tramadol- oral and weak opioid Methadone- not for acute pain
43
EXAM What are the steps to follow when switching between opioids
1. calculate consumption of each opioid per day 2. convert each opioid to oral morphine 3. Add morphine doses together to get total daily morphine dose 4.Due to cross tolerance, reduce dose by 25-50%
44
Breakdown the types of recommendations in the 2022 clinical practice guideline
1,2- determining whether or not to initiate opioids for pain 3,4,5- selecting opioids and determining opioid dosages 6,7- deciding duration of initial opioid prescription and scheduling follow up 8,9,10,11,12- Assessing risk and addressing potential harms of opioid use
45
Describe recommendations 1 and 2
Recommendation 1- Non opioid therapies are at least as effective as opioids for many types of acute painn(NSAIDs, antidepressant, acetaminophen) recommendation 2- Non-opioids preferred for subacute and chronic pain
46
Describe recommendations 3, 4, 5
3- When starting opioid therapy acute, subacute or chronic pain, clinicians should start IR opioids and not ER opioids 4- Use lowest effective dose 5- Carefully weigh risks and concerns when changing opioid dosage. Gradually taper to lower dose if benefits do not outweigh risk
47
Describe recommendations 8, 9, 10, 11, 12
8- strategies to mitigate risk (offer nakixone) 9- Clinicians should review patients history of controlled substance prescriptions to determine if patient is receiving opioid dosages that put them at risk for OD 10-toxicology testing to assess for prescribed medications as well as other prescribed and non prescribed controlled substance 11- use caution when prescribing opioids and BZDs concurrrently 12- Clinicians should offer or arrange treatment with evidence based medication. Detox on its own is not recommended
47
Describe recommendations 6 and 7
6- when pt is in acute pain, clinicians should prescribe no greater quantity than needed for expected duration of pain severe enough to require opioids 7- Evaluate benefit and risk with it within 1-4 weeks.
48
When to consider reducing/tapering doses of opioids
- no better pain control -patient asks - larger doses or concurrent BZDs -signs of OD/substance use
49
How to reduce and taper opioid doses
-Avoid abrupt discontinuation -decrease dose by 10% per month if patient has taken opioids for more than 1 year - Decrease dose by 10% per week for pts that have taken opioids for shorter time (weeks/months) -once lowest available dose is reached, interval between doses can be extended. May be stopped when taking < once per day.
50
What patients do Opioid laws apply to
-patients taking >60 opioid pills/month >3 months - using a transdermal patch > 3 months - tramadol >399 mg/day for > 3 months -taking any dose of an ER med
51
Who has exemptions from these opioid laws
Terminal condition, Palliative/hospice,
52
Describe the 2017 opioid 7 day law? Exemptions?
prescriber may not prescribe more than a 7 day supply except for cancer, MAT (medication assisted treatment), substance abuse disorder, palliative, professional judgement
53
Describe the 2019 inspect law
- requires checking INSPECT each time before prescribing an opioid or a BZD for pt NO EXCEPTIONS - check inspect every 90 days
54
Describe what a pain contract is
Agreement between patient and prescriber that says they wont get opioids from anyone else. Does not legally prevent another provider from prescribing opioids or pharmacy from filling.
55
for treatment of acute pain, can hospitals have multiple different medications for just one type of severity?
No, you can only have one for each level of pain.
56
What is PCA? When is it used?
Patient controlled analgesia. For patients in severe pain in hospital. (post OP, pancreatitis, sickle cell disease)
57
Recommend treatments for lower back pain
1st line- Acetaminophen NSAIDs 2nd- SNRI TCA Non- pcol- CBT, exercise, limit bed rest
58
Recommend treatments for osteoarthiritis
1st- Acetaminophen Oral NSAIDs 2nd- intra-articular hyaluronic acid Capscasin
59
Recommended treatments for fibromyalgia
Pregabalin Duloxetine
60
Recommended treatments for neuropathic pain
1st SNRIs Gabapentin/pregabalin 2nd- topical lidocaine TCAs
61
Treatment for pain relief and air hunger in hospice
-Morphine IV or sublingual (fentanyl/hydromorphone could also be used)
62
Treatment for anxiety/agitation in hospice pts
Lorazepam
63
Tx for N/V in hospice pts
Ondansetron ODT
64
How to treat secretions in hospice pts
Atropine Scopolamine Glycopyrollate
65

Therapeutics (38 decks)

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