Lecture 4.3 - Pain management (APAP & NSAIDs) Flashcards

1
Q

Primary indications for APAP & NSAIDs

A

pain relief for patients who do not respond to non-pharmacologic interventions

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2
Q

APAP vs NSAIDs

A

APAP: can be used in Mild-moderate pain but no chronic low back pain

NSAIDs: can be used n Mild, Moderate, Severe pain….they reduce inflammation unlike APAP

NSAIDs more effective but APAP better safety profile

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3
Q

APAP onset

A

30 min

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4
Q

APAP duration

A

about 4 hrs, 4-6hrs with ER formulation

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5
Q

Renal Dosing APAP

A

CrCl 10-50 = q6h

CrCl < 10 = q8h

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6
Q

SE APAP

A

Overall well tolerated

overdose
liver toxicity
GI ( 2g > day), nephrotoxicity (high dose, chronic use)

Max dose is 4g/day technically

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7
Q

When not to use APAP

A

Sig liver disease
Sig alcohol use > 3 drink/day
Achieving pain relief only at high dose

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8
Q

Should Not exceed how many days when using Ketorolac?

A

5 days of total use

inc in risk of adverse effects after that

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9
Q

Avoid oral diclofenac due to…

A

increased CV events
Causes more liver toxicity
More GI toxicity

topical is still okay

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10
Q

Max daily ibuprofen dose

A

RX: 3200mg

OTC: 1200mg

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11
Q

Max Naproxen sodium (IR) dosing

A

RX: 1375-1650mg

OTC: 660mg

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12
Q

General Naproxen Sodium & Ibuprofen Dosing RX vs OTC

A

RX: tend to be higher doses

OTC: tend to be lower

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13
Q

GI side effects from NSAID

A

Dyspepsia, ulcer, bleeding

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14
Q

How to protect Dyspepsia from NSAIDs

A
  1. Take w/ food
  2. Antacids
  3. Enteric coated, buffered, SR or PR dosage forms
  4. H2 blockers
  5. PPI
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15
Q

How to protect Ulcer/Bleed from NSAIDs

A

Enteric coating, buffering, SR DO NOT PROTECT FROM BLEEDING

using Selective NSAID (COX - 2 inhibitor) can help

negative effects due to COX-1 inhibition

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16
Q

Selective NSAID ulcer protection

A

Celecoxib

NTE: 200mg/day

If used with ASA, GI benefit is negated

Can also do a PPI add on, misoprostol, or high dose H2 blocker

17
Q

Non-selective NSAID ulcer protection

A

Ibuprofen likely more safe for GI compared to other non-selective NSAIDs

PPI add on is best, can also do misoprostol, or high dose H2 blocker

18
Q

When to stop NSAID prior to procedure?

A

Cox-2 inhibitor = stop day before

Non-selective NSAID = D/x 7 days prior

19
Q

Likely Safer nonselective NSAID for CV risk?

20
Q

NSAIDs are CI in what surgery?

21
Q

Low CV Risk, Low GI Risk give….

A

Celecoxib or other low-risk NSAID

22
Q

Low CV risk, Moderate GI risk give…

A
  1. Celecoxib alone

2. NSAID + PPI, misoprostol, or double dose H2-blocker (2nd line)

23
Q

Low CV risk, High GI risk give…

A
  1. Avoid NSAID if possible

2. Celecoxib + PPI or misoprostol

24
Q

High CV risk, Low GI risk give….

A

Naproxen or low-dose celecoxib

If on ASA = naproxen + PPI

25
High CV risk, Moderate GI risk give...
1. Naproxen + PPI, misoprostol, or double dose H2-blocker | 2. Low dose Celecoxib
26
High CV risk, High GI risk give...
Avoid NSAIDs
27
Low GI risk =
without risk factors
28
Moderate GI risk =
1 or 2 risk factors
29
Highest GI risk =
h/o complicated or recent ulcer, with more than 2 risk factors
30
GI risk factors
> 60yrs old current high dose of NSAID uncomplicated peptic ulcer history Concomitant use of ASA, Anticoagulants, corticosteroids
31
High CV risk considerations
h/o CV event, diabetes, HTN, hyperlipidemia, obesity
32
Taking NSAIDs with ASA then...
Take ASA first, NSAID 2nd and separate...dont take within 2hrs
33
Concurrent drugs that increase bleeding risk with NSAIDs
anticoagulants Steroids SSRIs
34
NSAID Kidney Adverse effects risk factors
Elderly Decreased renal function Volume depletion secondary to diuretics, cirrhosis or HF
35
DI that put you at risk for NSAID Kidney issues
Diuretics ACEi/ARBs All ant-HTN meds May inc toxicity of lithium and methotrexate
36
Topical NSAIDs are effective in....
surface level joints....ie shoulder, knuckles,etc