Module 12: MSK (a) Flashcards
1
Q
MSK Drugs
-Chronic Pain Tx Goal?
A
- Lessening the progression
2. Improving Function
2
Q
Pain Overview
-Nociceptive
A
- Adaptive (Protective) pain — sensed by pain receptors
- Somatic pain — MSK pain; Visceral pain - pain from organs Ex: bruise, burn, cut, fracture — May feel sharp, dull, throbbing, aching
3
Q
Pain Overview
-Inflammatory
A
- Adaptive (protective) pain — Results from local inflammation (Ex: Arthritis, infection, tissue injury)
—Some consider inflammatory pain a subcategory of nociceptive pain — May throb or ache
4
Q
Pain Overview
-Pathologic - Neuropathic & Central Pain
A
- Maladaptive pain — Damage or dysfunction of nervous system (Ex: DM, nerve injury, central pain disorders)
- Pain may be described as pain hypersensitivity “Nociplastic pain”
- Examples — Neuropathic pain, diabetic neuropathy central, nociplastic pain, fibromyalgia - Might feel electric, burning, pins and needles, tingling, shooting
5
Q
Pain Management Options For:
-Nociceptive Pain?
A
- NSAIDs
- Acetaminophen
- Muscle relaxants (For muscle spasm r/t pain — Cyclobenzaprine, tizanidine, baclofen
6
Q
Pain Management Options For:
-Inflammatory Pain
A
- NSAIDs (Ex: Ibuprofen, naproxen, Meloxicam, ketorolac, diclofenac topical gel
- Systemic steroid (Oral, IM, Intra-articular)
7
Q
Pain Management Options For:
-Neuropathic & Central Pain
A
Evidence for the following meds efficacy is mixed and limited
- Anticonvulsants (Gabapentin, Pregabalin)
- SNRIs (Duloxetine, milnacipran)
- TCAs (amitriptyline)
- Topical agents? (Lidocaine or capsaicin)
8
Q
NSAIDs
-Info
A
- Ibuprofen, Naproxen — Short-to-moderate acting & commonly used
- Meloxicam — LONG duration of effect — Slow onset
- Celecoxib — SELECTIVE COX-2 inhibitor w/ reduced risk of GI toxicity compared to nonselective NSAIDs
- Indomethacin — Most commonly considered w/ GOUT
9
Q
Acute Moderate-Severe Back Pain
-Treatment Options
A
- Initial therapy — NSAID 2-4 weeks
- For Severe pain:
- Ketorolac <5 days
- Tramadol <2 weeks
- Opiate 3-7 days
10
Q
NSAIDs
-A/Es
A
- Increased risk of GI bleeding
- When used long term, consider gastro-prophylaxis such as a PPI
- NSAIDs can cause or worsen renal impairment —AVOID in patients with CrCl < 60. Routinely monitor serum creatinine w/ dose changes
- CV disease and those at risk for CV disease — Nonselective NSAIDs reversible inhibit PLT functioning and cardio protective effects of ASA
- Take ASA and NSAIDs at least 2 hrs apart - NSAIDs can increase BP by diminishing efficacy of anti-HTN meds — Avoid NSAIDs in pt’s with difficult to control HTN
11
Q
NSAIDs
-Ketorolac
A
- Alt to narcotic analgesic — Used for moderately severe acute pain — DO NOT use longer than 5 days — IM injection
- DO NOT add to another NSAID
- MULTIPLE BBW — GI, CV, Renal, Bleeding/Labor & delivery risks, hypersensitivity reaction — including ASA or NSAID reactions
12
Q
Acetaminophen/Paracetamol
A
- First-line tx option in mgmt of mild persistent pain
- Lacks significant anti-inflammatory properties — Less effective for inflammatory pain than NSAIDS
- Can cause hepatotoxicity w/ chronic use
- Max dose is less than 3-4 grams in 24 hrs — Less than 2 grams in frail Pt’s and those >80 yrs
- For severe cases use an NSAID + Acetaminophen — Resembles an opioid
13
Q
Muscle Relaxants
A
- May provide analgesia and a degree of skeletal muscle relaxation or relief from muscle spasms
- A/Es include — Sedation, dizziness r/t CNS and Anticholinergic activity — Watch in older patients
- Educate Pt’s on impairment and sedation — Might take at bedtime d/t sedation
14
Q
Muscle relaxants
-Example Meds
A
- Cyclobenzaprine (Flexeril) — First line medication
- Methocarbamol (Robaxin)
- Carisoprodol (Soma) — Concerns for abuse — Controlled
Can cause Sedation
15
Q
Tramadol (Ultramar)
A
- Opiate analgesic (Codeine analog) w/ weak mu-receptor binding
- Potential risk of serotonin syndrome when combine w/ other SSRIs
- Option for severe or refractory pain — Short-term <2 wks (Schedule IV)
- Avoid in children, pregnancy/lactation
16
Q
Osteoarthritis in Older adult w/ Co-morbidities
-Tx options
A
- Topical NSAID — diclofenac gel or patch Topical NSAID— non-systemic acting
—Capsaicin cream — topical agent — Less expensive than NSAID — Can cause burning, stinging, and erythema - Oral NSAIDs work as well — NOT for CKD, HTN
- Duloxetine — SNRI is a good option for OA
- Intra-articular injections of corticosteroids (methylpredinisolone, triamcinolone) — Short term
—Potential risk — Continued injections can lead to progression of cartilage damage in knee OA
17
Q
Gout Tx
-Medication Options
A
- Thiazide diuretics are a risk factor for gout.
- Oral NSAIDs can work for treatment — Ex: Naproxen or Indomethacin — NO more than 5-7 days
- Corticosteroids — 1st line option — PO, Intra-articular injections or IM
- Colchicine — Start w/in 36 hrs of sx onset — Diarrhea most common A/E — Drug-drug interactions d/t CYP3A4 pathway
—Reserved for when an NSAID or steroid is not appropriate - Allopurinol — Used for PREVENTION of gout, NOT for treatment — Potential A/E’s SEVERE skin reactions: DC if rash occurs — Genetic test is recommended for some
18
Q
Neuropathic Pain
-Med options
A
1. Antidepressant — SNRI (Duloxetine) —TCAs ( Amitriptyline) OR 2. Anticonvulsant (Gabapentin, pregabalin)
19
Q
Duloxetine (Cymbalta)
-Uses/Info
A
- SNRI w/ CNS activity — largest evidence base to support analgesic efficacy
- FDA approved for diabetic neuropathy, fibromyalgia, chronic low back pain, OA (in addition to depression and anxiety)
20
Q
Gabapentin (Neurontin) & Pregabalin (Lyrica)
A
- Calcium channel antagonists — block release of neurotransmitters
- Pregabalin is controlled (requires DEA) and Gabapentin is controlled in many states
- Indicated in Tx of neuropathic pain — diabetic peripheral neuropathy, post-herpetic neuralgia, fibromyalgia
21
Q
TCAs for Pain?
A
- Amitriptyline, nortriptyline — NONE carry FDA label for pain management
- Amitriptyline has been most widely studied TCA in chronic pain — MOST SEDATING
- Associated w/ MULTIPLE AE’s — Start w/ Low dose
22
Q
Fibromyalgia
-Med options
A
- Amitriptyline — Less long-term benefit — causes sedation
- Pregabalin or Gabapentin (anticonvulsant) — Pain and sleep quality
- Cyclobenzaprine (Muscle relaxant) — No long-term, can help w/ pain and sleep
- Duloxetine or milnacipran (SNRI) — FDA approved for fibromyalgia
23
Q
Multimodal Approach to Pain
A
- Non-medication tx’s for pain are first-line d/t low risk w/ potential for great benefit and ultimate recovery
- Non-opioid pain medications can be used next
24
Q
Cannabis and cannabinoids
-Info
A
- AE’s — dizziness, dry mouth, n/v, fatigue, drowsiness, euphoria, confusion, hallucination and loss of balance — Do not drive
- Dronabinol and Nabilone — Approved for treatment of N/V w/ cancer chemotherapy
- Dronabinol is approved for anorexia associated w/ weight loss in Pt’s w/ AIDS
- Cannabidiol (Epidiolex) is approved for seizures — Lennox-Gastaut syndrome and Dravet syndrome
