FINAL pain Flashcards
difference between acetaminophen and ASA
no gib no platelet issues to CV or respiratory symptoms with Tylenol but it is not an ant-iinflammatory
can be used in pts with aspirin hypersensitivity in children or pregnant women (category C)
what is the dosing of ibuprofen
3200mg max dose in day
MENSS
200-800mg TID/qid
NASSA- FASS
naproxen dosing
250-500mg BID/TID
NaLgas-LeZZ
nuisance se of NSAIDS
nausea and dyspepsia
most common sx of NSAID
mucosal lesions
less than max dose may provide analgesic effect with less GI irritation
also important to note is that daily NSAID use may increase CV risk factor (not NAPROXEN)
gastrointestinal protection for NSAIDS
misoprostol
NOT FOR PREGNANT WOMEN council ALLL PTs men too
can also use PPI or H2 with non-selective NSAID
MOA of misoprostol
synthetic PG EQ with antisecretory effect on gastric acid secretion and mucosal protective properties
what is the ASA sensitivity triad
20% of asthmatics are sensitive to ASA and NSAIDS
major med interactions with NSAIDS
warfarin –> increased bleeds
ACE: increased renal dz
loop or K sparing diuretics: decrease diuretic effect
lithium: increase lithium level s
additional signs of ASA toxicity include
hyperthermia
hyperventilation
respiratory alkalosis
interaction with ASA and protein binding drugs
plasma levels increase disproportionately as dosing increases
protein bound drugs will increase as dose increases . whattttttt
if pt is taking ASA for CV risk
wait at least two hours before taking another NSAID if you really need to
UNLESS it is celecoxib or diclofenac which don’t have interactions
NSAID most commonly used in the hospital
ketorolac
one of the only ones available inj
can decrease opiate dose whne used in conjunction
ALWAYS LIMIT TO 5 DAYS
Cox 1 is responsible for
renal and platelet function as well as protecting gastric mucosa
which cox 2 inhibitor is still on the market
celecoxib (celebrex)
less GI and slightly better at pain control
most pulled off the market because of increase risk of CV dz and SJS
don’t take with ASA or else it is useless
Vicoprofen
combination opiod NSAID
hydrocodone and ibuprofen
groups of opiates
diphenylheptane
methadone
phenylpipedrine
fentanyl, meperidine, sufentanil, alfentanil
phenanthrenes
morphine, codeine, hydrocodone
these two opiates can both be used for post op shivering
fentanyl and meperidine
both part of the phenypiperidine family
partial Mu agonists
tramadol
centrally acting synthetic opioid analgesic
binds to mu-opioid receptors and weak inhibition of NE and serotonin reuptake
very low bioavailability with this opioid
fentanyl
which is why we see it in a patch, suckers, IV,
This opioid is seen with a larger Vd in the elderly
meperidine
probably just shouldn’t use it
(post op for shivers but really just use meperidine)
opioids that are metabolized in the liver and should be avoided with hepatic dysfunction
codeine
meperidine
diacetylmorphine
opoid receptro types: kappa
alaos produces analgesia similar to Mu
psychosis
slowed GI
AE of opioid use with acute use
respiratory depression N/V constircted pupils drowsy decreased consciousness of awareness constipation urinary retention
tolerance will never be developed to this SE of opioids
CONVULSIONS
miosis
constipation
sometimes you will see pts that build tolerance to this SE of opioids
bradycardia
how do you convert between opioids
convert to total daily dose equivalent of PO morphine
then reduce 25-50% for cross tolerance EXCEPT in methadone
weak inhibition of NE and serotonin uptake of this opioid means this drug has a max dose and has pasych and seizure caution
tramadol
adj needed w/ tramadol
hepatic and renal impairment
tramadol SE
can definitely cause respiratory depression
can see terrible effects in elderly with decreased renal infuction
why does tramadol suck
basically just as good as ibuprofen
when would you want to titrate fentanyl
not before the 6 day mark
it can take 6 days before you reach max
can technically do it day 3
removing the patch isn’t enough on overdose can take a day or two (usually 72 hours)
fentanyl patch is only good for
three days.
what are the adverse SE that should warrent caution with methadone
QT prolongation
hypotension
hypoglycemia
CVD dysrhythmia
rapid onset and 8x more potent than morhphine
rapid onset hydromorphone
also a C2 no rela benefit over morphone
what are we worried about with deMEROL (meperidine)
MEPERIDINE- can be used for shivering but
LITTLE ROLE IN PAIN MANAGMENET AND NO ROLE IN THE ELDERLY
TOXIC METABOLIE NORMEPERIDINE
renally excreted
longer half life so meds wear off before pain releif
you are going to be in perril if you try dem rolls but you can use it to try to stop rollin
CI with meperidine
MAO syndrome if combined with MAOI
opioid like compounds
dextromethorphan
robo tripping (robitussin)
codeine/guaifensesin
diphenoxylate/atropine
lomotil antidiarrheal med
atropine is to avoid abuse potential
loperamide is similar but dose not cross BBB= no abuse
what drugs would you not want to give to naive opioid user
fentanyl or methadone
cardiovascular effects of opioids
peripheral vasodilation (histamine release) cerebral vasodilation (increase intracranial pressure) orthostatic
GI effects of opioids
increased tone and decreased activity lead to constipation
potential smooth muscle spasm
what are the potential pt risk for severe SE w/ opioids
pts with head injuries with CO2 retnetion and ICP
BREASTFEEDING
imparied pulm function (OSA)
impaired hepatic or renal fucntion
endcrine disease can have prolonged exaggerated response
opioids you want to avoid with impaired renal function
morphine
hydromorphone
codeine
buprenorphene MOA
partial agonist
activates at lower levels
relatively less reinforcing
can displace full agonsits like heroin and methadone
disassociates very slowly blocking heroin and methadone binding
CI of buprenorphine
can precipitate opioid WD similar to naloxone
but less dangerous because you fall to partial agonist
shorter the half life the grater that abuse potential
what are other factors effecting abuse potential
lipophilicity (faster across BBB)
heroin>morphine>methadone
degree of Mu activity
will feel w/d much more quickly
buprenorphine
can be used for pain but can’t prescribe without additional training
preferred form form for unsupervised dosing
buprenorphine
methadone you need supervised
Nalozone differs from buprenorphine because
it is an antagonist
completely blocks
morphine and amphetamines are all what durg class
II
VICODIN is what schedule of drug
III
PB and ambien are both what durg class
IV
lomotil and low amounts of codeine are what drug class
V
refill restrictions for drug classes
CII- no refills
CIII-V: 5 refills
