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neurology/psychiatry > Lowry: Pain > Flashcards

Lowry: Pain Flashcards

1
Q

definition of chronic pain

A

pain lasting >12 weeks or >3 months

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2
Q

3 types of physical pain

A

somatic pain
visceral pain
neuropathic pain

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3
Q

somatic pain

A

pain arising from damage to muscle/bone/skin (LOCALIZED)
descriptors may be sharp, intense, throbbing, localized

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4
Q

visceral pain

A

pain arising from damage to organs; not well localized (can be referred)
descriptors may be gnawing, cramping, squeezing, diffuse, distant

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5
Q

neuropathic pain

A

pain arising from a lesion or disease of the somatosensory nervous system
descriptors may be shooting, burning, numb, tingling, enhanced sensitivity to heat/cool

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6
Q

what are the chronic non-cancer pain syndromes

A

osteoarthritis
diabetic neuropathy
fibromyalgia
post-herpetic neuralgia

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7
Q

what is osteoarthritis

A

common degenerative disorder of the joints leading to hypertrophic bone changes
ASYMMETRIC
common in hands, knees, hips, spine
symptoms would be persistent joint pain, stiffness, locomotor restriction

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8
Q

general treatment algorithm for osteoarthritis

A

from first to last line:
-non-pharm: exercise, physical therapy
-acetaminophen
-topical NSAID before systemic NSAID
-consider opioid therapy but not really
-consider corticosteroid injection
-consider hyaluronic injection
-discuss total joint replacement

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9
Q

what is diabetic neuropathy

A

nerve damage caused by poorly controlled diabetes that leads to numbness in extremities
the most common microvascular complication of diabetes
symptoms are unprompted numbness, tingling, burning, shooting (SYMMETRICAL)

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10
Q

general treatment algorithm for diabetic neuropathy

A

from first to last line:
-non pharm (optimize glycemic control)
-duloxetine, pregabalin, gabapentin
-venlafaxine, amitriptyline, lidocaine patch, capsaicin cream/patch, tramadol, tapentadol

duloxetine and pregabalin are the drugs actually FDA approved for diabetic neuropathy

OPIOIDS AREN’T RECOMMENDED; last ever line.

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11
Q

what is fibromyalgia

A

widespread soft tissue pain affecting muscles, ligaments, tendons with no obvious objective abnormalities: unknown pathophysiology but there is diffuse musculoskeletal pain present for >3 months often with fatigue, headache, etc

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12
Q

_____ may exacerbate fibromyalgia

A

weather

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13
Q

general treatment algorithm for fibromyalgia

A

Non pharm: education, CBT, physical therapy, exercise, acupuncture, hydrotherapy
Sleep disturbance: amitriptyline, cyclobenzapine, pregabalin (FDA approved), gabapentin
Depression/anxiety: duloxetine (FDA approved), milnacipran (FDA approved), amitriptyline, pregabalin

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14
Q

what is postherpetic neuralgia

A

pain in a dermatomal distribution caused by nerve damage secondary to an inflammatory response induced by viral replication (herpes zoster shingles) within a nerve sustained for at least 90 days after acute herpes zoster

symptoms are burning, shock like pain may be associated with allodynia or hyperalgesia

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15
Q

allodynia vs hyperalgesia

A

allodynia: pain from stimuli that are not normally painful
hyperalgesia: abnormally heightened sensitivity to pain

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16
Q

when can you receive shingles vaccine with postherpetic neuralgia

A

after rash has gone away

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17
Q

general treatment algorithm for postherpetic neuralgia

A

treat acute herpes zoster with antivirals
first line: gabapentin, pregabalin, lidocaine patch, capsaicin patch all FDA approved
second line: TCAs
third line: opioids, not preferred, why would you do this

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18
Q

when would acetaminophen be used

A

OA, musculoskeletal pain
3g/day OTC, 4g/day Rx

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19
Q

when would NSAIDs be used

A

OA, reduce inflammation
Topical for localized pain with miniscule systemic absorption making them well tolerated

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20
Q

counseling points for topical NSAIDS

A

apply 2-4 g to affected area QID
max dose is 32 g/day
effects will be seen in 10-14 days

21
Q

cautions with NSAIDs

A

CV, renal, and GI side effects are super worrisome in older adults

22
Q

systemic NSAIDs from most COX2 selectivity to most COX1

A

meloxicam
celecoxib
diclofenac
ibuprofen
naproxen
indomethacin
ketorolac

23
Q

when are SNRIs used
which SNRIs are used

A

neuropathic pain
venlafaxine, duloxetine, milnacipran

24
Q

when is pain improvement seen with SNRIs

A

4 weeks

25
Q

pearls for SNRIS

A

dose adjust CrCL<30
caution in hepatic impairment
can cause wt loss, dec appetite, drowsy, serotonin synd

26
Q

when are TCAs used
which TCAs are used

A

neuropathic pain
amitriptyline, nortriptyline, desipramine

27
Q

when is improvement seen with TCAs

A

4 weeks

28
Q

TCA cautions

A

older adults– anticholinergic (Beers criteria)
sedation, QTc prolongation

29
Q

what are calcium channel blockers for and which ones are used

A

neuropathic pain
gabapentin, pregabalin

30
Q

when is improvement seen with calcium channel blockers

A

2 weeks

31
Q

calcium channel blockers pearls/cautions

A

CNS depression, respiratory depression, drowsiness, peripheral edema
renally adjust

32
Q

when are sodium channel blockers used
which ones are used

A

chronic pain syndromes (like migraines, trigeminal neuralgia, etc)
carbamazepine, oxcarbazepine, phenytoin, valproic acid, topiramate

33
Q

when are skeletal muscle relaxants used
which ones are used

A

pain related to muscle spasms
cyclobenzaprine, methocarbamol, tizanidine, baclofen, carisoprodol, metaxalone

34
Q

muscle relaxer pearls

A

avoid use in elderly
drowsiness, confusion, dizziness, fatigue, Beer’s criteria

35
Q

when are opioids used for chronic non-cancer pain

A

LAST line
efficacy is questionable

36
Q

which NSAIDs are the worst offenders for cardiovascular risk

A

celecoxib and diclofenac

best is naproxen

37
Q

which NSAIDs are the worst offenders for AKI

A

naproxen, ibuprofen

best are celecoxib and diclofenac

38
Q

which NSAIDs are the worst GI offenders

A

ketorolac

best are celecoxib and ibuprofen

39
Q

high GI risk with NSAIDs

A

age >65, history of ulcer disease, previous GI bleed, DAPT, anticoagulant therapy, corticosteroid use, GERD

prescribe PPI

40
Q

what are the topical non-NSAID agents

A

capsaicin (OTC cream, Rx patch called Qutenza applied at Dr. office)
lidocaine
analgesic balms like Tiger Balm, Icy Hot, Bengay

41
Q

what is the Qutenza patch indicated for

A

diabetic neuropathy, postherpetic neuralgia

42
Q

when is capsaicin helpful

A

pain that responds to heat

43
Q

when is relief seen with capsaicin

A

2-4 weeks

44
Q

counseling for capsaicin

A

do not use heating pads. wash hands after. ADEs are application site pain, burning, erythema

45
Q

lidocaine patch counseling points

A

apply for 12 hours then remove for 12 hours
max 3 patches per day. can cut them and place them on different sites

46
Q

when is relief seen with analgesic balms like icy hot

A

x1-3 hours

47
Q

advantages of pregabalin

A

faster onset of pain relief
higher bioavailability
dose can be titrated to effective dose more rapidly
less pill burden (BID dosing)

48
Q

disadvantages of pregabalin

A

higher risk of peripheral edema
schedule V
more expensive, prior auth
dose reduction necessary for renal impairment (gabapentin requires dose adjustment too tho)

neurology/psychiatry (22 decks)

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