exam 5 pain rogers Flashcards
How is pain classified?
acute vs chronic
noiceptive or neuropathic or both
what are some non-pharmacological therapies for pain?
exercise, correct cause, physical manipulation, heat/ice accupuncture, massage
used in combo with analgesics
what is the treatment approach to pain therapy?
step 1: non opioid +/- adjuvant analgesic
step 2 + 3: opioid + nonopioid +/- adjuvant analgesics
what are non-opioid analgesics?
APAP
NSAIDs
what are adjuvant therapies?
gabapentinoids
SNRIs
TCAs
Skeletal muscle relaxants
antiepileptics
topical agents
what are the formulations of APAP?
tablet, capsule, chewable, liquid, IV, suppository
what is dosing, side effects, and clinical pearls of APAP?
adults: 325-1000mg PO q4-6h prn max 3-4g/day, max 2g in liver disease pts
PEDs: 10-15mg/kg PO q4h PRN, max dose 3-4g/day
sides: hepatotoxicity likely with >10g dose
pearls: gold standard for OA due to fewer sides than NSAIDs
what are side effects and clinical pearls of NSAIDs?
GI bleeding, nephtotoxicity, fluid retention, increased CV events
take with food, caution use in geriatric patients (BEERs), avoid systemic NSAIDs in patients with cardiac history, avoid severe liver or kidney disease
what is aspirin formulations?
chew, EC, capsule, ER, suppostitory
what are dosing and clinical pearls for aspirin?
adults: 325-1000mg q4-6h PRN (max 4g/day)
PEDs: not recommended due to reyes syndrome
clinical pearls: avoid in blood thinners due to antiplatelet activity
what is reyes syndrome?
associated with children and teens when using ASA and they have a viral infection
rare condition causing swelling in brain and liver
what are ibuprofen formulations?
suspension, chewable, IV
what is ibuprofen dosing?
adults 200-800mg PO q6-8h PRN
max 3200mg
PEDS: 5-10mg PO q4-6h PRN max 2400mg
what are diclofenac formulations?
IV, suppository, topical gel, topical solution, opthalmic, patch
what are naproxen formulations?
ER tablet, suspension
what are ketolroac formulations?
IV/IM, nasal spray, opthalmic solution
what is important about ketorolac?
maximam duration of 5 days
oral dosing is only for continuation of IM or IV therapy
what are celebrex formulations?
capsule and oral solution
what is important about celebrex?
COX 2 selective
what are the formulations for gabapentinoids?
ER and liquid
what is important a gabapentinoids?
Gabapentin dosing: 100-300mg po TID max dose 3600mg
pregabalin dosing: 75mg PO BID max 600mg/day
titrate up slowly to limit sedation
what is are the formulations of SNRIs?
capsule/tab
ER
what drug should be avoided in patients with CrCl <30mL/min
duloxetine
renal dose adjustments needed for venlafaxine
what are the formualtions for TCAs?
amitriptyline: tablet
nortriptilylin: capsule and oral solution
what are the formulations for muscle relaxants?
tablet/capsule (IR/XR)
what are the available formulations for carbamazepine?
ER capsule/tablet
suspension
which drug has increased hypersensitivity with HLAB-1502 allee?
carbamazepine
also has autoinduction of enzymes
what is important about lidocaine?
tachyphylaxis with continous use
12 hour break between patches
less systemic sides
what is capsacian used for?
muscle/joint pain
neuropathic pain
what drugs should be avoided in the elderly?
Non COX2 selective
indomethacin + ketorolac
skeletal muscle relaxants: carisoprodol, cyclobenzaprine, methocarbamol
opioids and BZDs
opioids and gabapentinoids
anticholinergics
combination of these 3 or more
what should be used with caution in the elderly?
SNRIs
TCAs
Carbamazepine
what are side effects of opioids?
antitussive, constipation, N/V, itching, orthostatic hypotension, respriratory depression
can start stool softener or stimulant laxative
what is codeine?
metabolized to morphine via CYP 2D6
what is tramadol?
US boxed warning use of 3A4 inducers, inhibitors, 2D6 inhibitors require careful dosing considerations
what is morphine?
itching is predominant compared to other opioids
morphine and metabolites are renally excreted and can accumulate in renal dysfunction
Avoid alcohol when taking capsules
what is hydromorphone?
solution for injection, suppository
boxed warning: medication errors
what is us boxed warning: use with CYP 3A4 inhibitors may increase levels
hydrocodone, oxycodone, fentanyl, tramadol, methadone, merpiridine
what can be used in renal impairment?
fentantyl
what is important about methadone?
qt prolongation
what are natural opioids?
morphine
codein
what are semi-synthetic opioids?
hydromorphone
oxycodone
oxymorphone
hydrdocodone
buprennorphine
what are synthetic opioids?
fentanyl
methadone
meperidine
tramadol
what should be given in patients with allergies to semi-synthetic or natural opioids?
synthetic opoiods
fentanyl
methadone
mepiridine
tramadol
how do you reduce/ taper and opioid?
decrease by 10% per month if pt has been on it for 1+ years
decrease by 10% per week if patient has been on it for weeks to months
what is treatment for acute pain?
PRN analgesia
around the clock analgesia
what is michigan OPEN?
recommended APAP and ibuprofen q6h while awake
what is treatment for acute pain in the hospital?
can only have one order for each severity of pain
what is the recommended treatment for low back pain?
nonpharm - exercise, CBT, rehab
first line: APAP and NSAIDs
second line: SNRIs and TCAs
what is the treatment for OA?
nonpharm - excercise, weight loss, education
firstline: APAP and NSAIDs
second line: intra-articular hyaluronic acid or capsaicin
what is treatment for mibromyalgia?
nonpharm: exercise, CBT, rehab
medications: FDA pregabalin, duloxetine
other options: gabapentin, TCAs, venlafaxine
what is treatment for neuropathic pain?
first line: SNRIs, gabaptentin/pregabalin
second line: topical lidocain, TCAs
what are the hospice medications?
pain relief: morphine
anxiety/agitation: lorazepam
N/V: ondansetron ODT
secretions: atropine, glycopyrrolate, scopalamine
