MSK Flashcards
Acute Pain
Temporary pain, serving as a warning that something is wrong and usually resolves as healing occurs
Chronic pain
Pain that persists for 3 or more months.
Significant emotional distress present
Nociceptive pain
Tissue damage often from injury, inflammation, or disease.
Typically acute pain.
May feel throbbing, aching, or sharp.
Neuropathic pain
Nervous system damage from peripheral or CNS dysfunction.
Often chronic pain.
Feels burning, tingling, or numb
Nociplastic pain
Neural pain despite no evidence of nervous system damage.
Presents similar as neuropathic pain
Cancer pain
Presents as both nociceptive and neuropathic
Hyperalgesia
increased sensitivity to pain
What is essential to success in pain therapy?
Nonpharmacological therapies are most effective treatment
e.g psychological, physical/rehab, device/prodecure, self management, etc.
Factors of pain
Biological, psychological, social, and cultural
What pain medications are safe in pregnancy and lactation?
P: acetaminophen, methadone, suboxone, nortripyline, (oxycodone, morphine, fent in 1st and 2nd trimesters)
L: acetaminophen, suboxone, nortripyline, morphine, fentanyl, hydromorphine, NSAIDs
Preferred pain agents in impaired renal function
Acetaminophen, hydromorphone, oxycodone, methadone, TCAs
Decrease doses of gabapentin, pregabalin, venlafaxine, tramadol
Preferred pain agents in hepatic dysfunction
NSAIDs (avoid child pugh C), acetaminophen (prolonged use reduce dose)
Caution with opioids and avoid SNRIs
What pain meds to avoid in geriatrics?
Anything that affect the CNS and increase risk of falls, i.e. TCAs, SNRIs, muscle relaxants, opioids, cannabinoids, gabapentinoids)
Why to avoid indomethacin in geriatrics?
increased risk of CNS harms
Treatment options for Trigeminal neuralgia
Anticonvulsants: CBZ (DOC), gabapentin, lamotrigine, phenytoin
Topical anesthetics: Botox (if CBZ not tolerable)
Drug causes of TN: digoxin, macrobid
Diabetic neuropathy treatment options
TCAs, SNRIs, gabapentin, pregabalin, valproate, lamotrigine, SSRIs, capsaicin
Treatment options for post-herpatic neuralgia
TCAs, SNRIs (duloxetine), gabapentin, pregablin, divalproex, opioids, capsaicin
Treatment options for post stroke
TCAs, lamotrigine
Treatment options for spinal cord injury
They all suck but Gabapentin, pregabalin, lamotrigine, strong opioids controversial, ketamine, baclofen for spasm, amitripyline if depressed, valproate not useful
Post mastectomy treatment options
Capsaicin, venlafaxine, amitripyiline
Phantom limb pain treatment options
Gabapentin, opioids, ketamine, or CBZ or propranolol are also options
Complex regional pain syndrome treatment options
TCAs and anticonvulsants options but lack data, opioids?, NSAIDs?, bisphosphonates, prednisone, nifedipine
Fibromyalgia treatment options
Exercise, CBT, aquatic exercise, medical bathing
TCAs, cyclobenzaprine, SSRIs, SNRIs, antiepileptics
Treatment for daily chronic headache
Amitriptyline, SSRIs, divalproex, topiramate, gabapentin, botox
MSK Non OA pain treatment options
Non drug TX!
NSAIDs useful in acute
Opioids
Osteoarthritis treatment options
Acetaminophen, NSAIDs (more effective), duloxetine for knee, intra-articular corticosteroid injection for knee, viscosupplement, opioids
Concomitant psychological factors may consider using…
Depression: TCA, venlafaxine, SSRI, mirtazapine
Insomnia: TCA, trazodone, mirtazapine
Bipolar: CBZ, divalproex, lamotrigine
Weight gain: topiramate, gabapentin, nortriptyline
Adequate trial for TCAs for pain
2 weeks at adequate target dose and increase dose every 1-2 weeks
effective in sleep and neuropathic pain
Low back pain nonpharm therapy
Activity as tolerated, physiotherapy, spinal manipulation, psychosocial intervention, multidisciplinary intervention
Pharmacological treatment options in low back pain
NSAIDs: effective in acute LBP mod-sev, somewhat effective in chronic LBP
Acetaminophen +/- codeine: option but ? benefit
Opioids: not generally recommended, use for <3 days
Muscle relaxants: possible short term role, <1-2 weeks, mixed evidence and studies do not support chronic use in LBP. Linked with sedation
Antidepressants: Duloxetine for chronic LBP. Other antidepressants if comorbidities. TCAs possible
Anticonvulsants: option if neuropathic
A/E of muscle relaxants
Drowsiness, impaired cognitive function, falls, dependence, hepatic toxicity with chronic use.
Drug interactions of muscle relaxers
1A2 inhibitors (cipro), hypotension
What is gout?
Uric acid crystals (needle like) deposited in joints, nephrons, and tissues
Serum uric acid levels often elevated due to decrease in excretion or increased purine breakdown
Causes or risk factors of Gout
The 3 D’s
Drugs: ACE/ARBs, acetazolamide, ASA, chemo, cyclosporine, diuretics (loops and thiazides), ethambutol, lead, levodopa, niacin, ritaonvir, tacrolimus
Disease: malignancies, CKD, HTN, obesity, hyperglycemia, hyperlipidemia, surgery, trauma
Diet: purine rich foods (alcohol, fish, red meat)
Gout flare
Intense pain –> redness, heat, swelling, more often at night and in the big toe
Stages of Gout
1: Asymptomatic Hyperuricemia: elevated uric acid without sx (<25% develop gout and typically does not require drug tx)
2: Acute gouty arthritis: wuick onset, usually one joint, may self resolve within 14 days
3: Intercritical gout: sx free period but disease may progress
4: Chronic tophaceous period: progression to tophi, bony erosins, deformations, nephropathy, kidney stones
Non pharm for gout
Diet (low cal), lifestyle like weight loss, smoking cessation, exercise, etc. Rest, elevate, ice limb, (heat dissolves crystals but increases inflammation)
Treatment for acute attack of gout
Rapid tx is key (<24 hr) after onset to decrease inflammation and pain.
Colchicine, NSAIDs, or corticosteroids all 1st line, start at high dose and taper
Combo may be appropriate if severe
Avoid adjusting allopurinol
Maintenance/prophylaxis gout therapy
Prevent flares and treat when sUA levels over 800, 2 or more flares per year. chemo, advanced damage, CKD
Allopurinol 1st line and waiting 1-2 weeks post flare is reasonable as weak evidence during (start low to avoid A/E and can prophylax with colchicine or NSAID (not ASA) will titrating for 3-6 months to prevent flares
NSAIDs MOA for Gout
Cyclooxygenase inhibitors to decrease pain and inflammation
Indicated for acute attack or when initating allopurinol
Colchicine MOA for Gout
Decrease urate crystal deposition and pain/inflammation
Indicated for acute gout attacks, prophylaxsis, or when initating allopurinol
Corticosteroids MOA for Gout
Decrease pain and inflammatory response, effectvie for gout but not officially indicated
Useful if CI to NSAIDs
Xanthine Oxidase Inhibitor MOA
Allopurinol, Febuxostat
Decrease uric acid production
Indicated for prophylaxis
Colchicine A/E
N/V/D (limit to <3 tabs on day 1, then 1-2 tabs/day will decrease), rash, alopecia
Serious: neutropenia, myopathy, rhabdo
Colchicine CIs
Blood dyscrasias, solid organ transplant, ?dialysis
Caution: renal function (decrease dose)
Colchicine DIs
Cyclosporine (increase myopathy), P-gp, 3A4 (ketoconazole, macrolides, verapamil, etc)
Allopurinol A/Es
Rash, diarrhea, hypersensitivity syndrome, SJS
Precaution: renal dysfunction, acute gout, liver dysfunction
Allopurinol DIs
rash when used with penicillins, antacids, thiazides, ACEi
Azathioprine, cyclophosphamide, theophylline, warfarin
How to decrease A/E of allopurinol?
Start low and go slow with titration
Increase by 100mg Q2-4W, half that dose if elderly
NSAIDs A/E, CIs, DIs
A/Es: GI upset, CNS effects with indomethacin (headache, drowsy, confusion)
CIs: decrease in renal, GI ulcer, HF, transplant (can use in CKD state 1 and 2)
Caution: CVD (celecoxib CI)
DI: lithium, ACEi/ARBs (increase K+)
Corticosteroids A/E, DIs
A/E: rare in short term, caution in long term. Insomnia, increase in BP/BG, GI upset, mood changes. Serious: edema/HF.
Caution: infections, immunosuppression
DIs: vaccines
Febuxostat A/Es, DIs
A/E: increase in LFTs, nausea, arthralgia, rash. Serious: HF/MI
