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Clinical Pharm > MSK cases > Flashcards

MSK cases Flashcards

1
Q

What is the goals of pain?

A

Decreased pain
Decreased healthcare utilization
Improved functional status
Improved quality of life

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2
Q

T/F goal of management is no pain

A

false, its decrease pain

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3
Q

What are the non-pharmacologic tx?

A

Heat/cold
Meditation/Relaxation
Guided imagery
Acupressure/acupuncture
TENS units
Physical Therapy
Chiropractic Care
Behavioral Therapy
Cognitive/Behavioral Therapy
Therapeutic Massage

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4
Q

What are pharmacologic treatment?

A

NSAIDS
Non-opioid analgesics
Anti-seizure medications
Anti-depressants
Opioid analgesics
Local anesthetics

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5
Q

Whats heat/cold therapy is recommended?

A

Ice for the 1st 24hr

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6
Q

What are some of invasive therapies?

A

Trigger Point Injections
Joint Injections
Regional Nerve Blocks
Epidural Injection
Various Surgeries

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7
Q

Whats the MOA of APAP?

A

Inhibit the syntheses of prostaglandins in the central nervous system

Works peripherally to block pain impulse generation

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8
Q

Is APAP a good or poor inhibitor of platelet function?

A

Poor inhibitor of platelet function

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9
Q

Does APAP a good or poor anti-inflammatory properties?

A

Poor/little

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10
Q

What is the safest meds for pt who are on blood thinners?

A

APAP because doesn’t do anything to platelet function

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11
Q

Whats the dosing for APAP?

A

325mg, 500mg (Extra Strength), and 650mg (Arthritis)

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12
Q

What is the max dose for APAP

A

4 grams

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13
Q

In elderly pt whats is the max dose for APAP?

A

3 gram

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14
Q

What is APAP most commonly used for?

A

Anti-pyresis
Relief of pain from:
Osteoarthritis
Migraine headaches
Skeletal pain
Muscular pain
Pain in pregnant women

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15
Q

What is the pain relief of choice in preg?

A

APAP

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16
Q

What is the antidote for APAP?

A

N-acetylcystine (Mucomyst)

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17
Q

What is the MOA for ASA?

A

Reduces prostaglandin and thromboxane A2 synthesis
Reduces platelet aggregation
Irreversibly inhibits platelet function for the life of the platelet, interfering with hemostasis and prolonging bleeding time

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18
Q

Who should you be careful with for ASA?

A
  • Gastrointestinal tract injury/upset
  • Renal injury
  • Viral syndromes in children and teenagers -risk of Reye syndrome
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19
Q

T/F A single dose of aspirin can precipitate asthma in aspirin-sensitive patients

A

True

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20
Q

Whats the dosing for ASA?

A

81mg (baby), 325mg, 500mg (Extra-strength)

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21
Q

When is ASA commonly used?

A

Anti-coagulation
Anti-pyresis
Relief of pain from:
Osteoarthritis
Migraine headaches
Muscular pain

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22
Q

Which ones are Non-selective NSAIDs inhibit COX-1 and COX-2?

A

Ibuprofen
Naproxen
Naproxen sodium

Indomethacin
Etodolac
Diclofenac
Sulindac

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23
Q

Which one is the only NSAID inhibit COX-2

A

Celecoxib

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24
Q

T/F

A

Some patients may respond better to one NSAID than another

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25
Q

When is NSAIDs commonly recommended?

A

Anti-pyresis
Relief of pain/inflammation from:
Dysmenorrhea
Migraine/tension headaches
Muscular/tendinous pain/strain/sprain

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26
Q

Which NSAID has less GI s/e?

A

Celecoxib

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27
Q

What is the choice of drug cramps etc?

A

NSAID but avoid in pregnancy

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28
Q

Can you give NSAID to Fx pt?

A

No

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29
Q

what is a High non-union fx?

A

schapoid

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30
Q

Can you give NSAID for pt with renal dfx?

A

NO

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31
Q

Can you give NSAID for pt with uncontrolled HTN?

A

No

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32
Q

When should you be caution in with NSAIDs?

A

Current nausea/vomiting
GERD

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33
Q

What are the topical NSAID?

A

Diclofenac sodium 1% gel (voltaren gel)

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34
Q

T/F Diclofenac is safer than systemic NSAID

A

True

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35
Q

What is example of one topical anesthetic?

A

Lidocaine (patces, gel, cream and spray)

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36
Q

What topical has been approved for tx of posthherpetic neuralgia?

A

8% capsaicin patch (Qutenza)

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37
Q

What is the parenteral NSAIDs?

A

Ketorolac - mc used injection

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38
Q

How long can you use ketorolac?

A

short-term, up to 5 days

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39
Q

What is s/e of ketorolac?

A

Severe GI toxicity can occur, particularly in the elderly

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40
Q

What can develop after one use of ketorolac?

A

acute renal failure

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41
Q

When is Toradol MC recommended for?

A

Migraine headaches
Renal Colic

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42
Q

what are the ADEs for NSAIDs

A
  • Exacerbation or development of CHF
  • Increased BP
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43
Q

T/F Hepatotoxicity does not occur with NSAIDs

A

False, it can, we use it if they do have liver failure

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44
Q

Can you use Aspirin and ibuprofen?

A

yes but not long term

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45
Q

Chronic switch??

A

Meloxicam

46
Q

What can celebrex do with warfarin?

A

Increase INR/PT, but the effect is unlikely to be clinically significant.

47
Q

Is there antidote for NSAIDs?

A

None

48
Q

Know how to calculate MME

A
49
Q

Which ones are the stronger opioids?

A

Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone, Oxymorphone

50
Q

Which one is weaker opioids?

A

Hydrocodone, Codeine, Tramadol

51
Q

T/F Unlike NSAIDs, these opioids generally does have ceiling

A

False, they DON”T have ceiling effect

52
Q

IS Vicodin weaker?

A

yes

53
Q

What combo with opioids should you be caution with?

A

opioids combined with APAP or an NSAID (Vicodin, Vicoprofen, Percocet)

54
Q

What is the semi-synthetic derivative of morphine, only aval in oral formulation

A

Oxycodone (Percocet, OxyContin)

55
Q

What is bioaval with oxycodone?

A

high in oral dosage, with a half-life of 2.5 to 3 hours

56
Q

Which is stronger? Oxycodone or codeine?

A

Oxycodone

57
Q

What is the formulation for hydromorphone?

A

parenteral (IV, IM, PO) short- and long-acting oral formulations

58
Q

When is hydromorphone preferred over morphine?

A

In pt with renal failure

59
Q

Whats another name for hydromorphone?

A

Dilaudid

60
Q

What is the onset of action for hydromorphone?

A

30 min for 4 hours

61
Q

What are the available formulation for fentanyl

A

IV, intrathecal, epidural, transdermal and oral transmucosal use

62
Q

Fentanyl is approximately ____ times more potent

A

80

63
Q

Whats the pro of transdermal fentanyl?

A

For pt with difficulty swallowing or malabsorption

64
Q

What can increase the release of the fentanyl?

A

Exposing to heat/ high fever

65
Q

what DDI can cause increase in fentanyl?

A

Inhibitors of CYP3A4

66
Q

What are two meds that inhibit CYP3A4 and increase fentanyl?

A

Ketoconazole and clarithromycin

67
Q

Whats fentanyl lozenge on a stick called?

A

Actiq

68
Q

When can Actiq be used?

A

Cancer pt already taking strong opioids

Rapid absorption from buccal mucosa and slower GI absorption

69
Q

What are the formulation of fentanyl?

A

Buccal soluble (Onsolis)
Sublingual (Abstral)
Nasal Spray (Lazanda)
Sublingual spray (Subsys)

70
Q

Codeine is about ____ % of more potent than morphine?

A

50%

71
Q

What is the dosage that Codeine is not tolerated?

A

65mg

72
Q

Whats hydrocodone + APAP called?

A

Vicodin, lortab, norco

73
Q

T/F Tramadol is NOT opiate?

A

False, it is!

74
Q

Whats the MOA of Tramadol?

A

Opioid AGONIST that binds to mu receptors blocking the reuptake of norepinephrine and serotonin

75
Q

How many black box warning does tramadol have?

A

8

76
Q

How is tramadol metabolized?

A

P450

77
Q

What are the S/E for tramadol?

A

Lowers seizure threshold
Prolonged- QT
Resp depression

78
Q

T/F Tramadol is associated with withdrawal and overdose at comparable rates to other opiates

A

TRUE!

79
Q

How does tramadol work with SSRI and SNRI?

A

Inhibits both serotonin and NE reuptake

80
Q

LOOK at slide 36

A
81
Q

Whats the antidote for narcotics?

A

Naloxone (Narcan)

82
Q

What is the mainstay of treatment for neuropathic pain?

A

Antidepressant and anticonvulsants

83
Q

T/F Combination use of antidepressant and anticonvulsant medication may produce synergistic increases in analgesic effect in neuropathic pain syndromes

A

True

84
Q

What are example of TCA?

A

Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Imipramine (Tofranil)

85
Q

TCA are best for what types of pain?

A
  • Neuropathic pain
  • Diabetic neuropathy
  • Postherpetic neuralgia
  • Polyneuropathy
  • Fibromyalgia
  • Nerve injury
86
Q

Are SSRI or TCA’s more effective for neuropathic pain?

A

TCA

87
Q

When is gabapentin effective?

A

Postherpetic neuralgia and diabetic neuropathy

88
Q

What is the S/E of gabapentin and pregabalin?

A

Dizziness and somnolence

89
Q

What is pregabalin used for?

A
  • Postherpetic neuralgia
  • diabetic peripheral neuropathy
  • Fibromyalgia
90
Q

What are the pros of pregablin vs gabapentin?

A
  • Titrated faster
  • Given wice a day vs. three times a day
91
Q

When is carbamazepine used?

A

Trigeminal neuralgia

92
Q

Whats the s/e of lamotrigine?

A

Rash –> SJS

93
Q

What two meds is used for migraine ppx?

A
  • Sodium valproate
  • Topiramate
94
Q

What may enhance analgesic effects of APAP, ASA and ibuprofen?

A

Caffeine

95
Q

What med can be added for analgesic in postop and CA pt?

A

Hydroxyzine

96
Q

What can prodice analgesia in some pt with inflammatory dz or tumor infiltrates of nerves

A

Corticosteroids

97
Q

Whats the name of alpha 2-adrenergic agnoist?

A

Clonidine

98
Q

Clonidine may improve what? (2)

A

Pain and hyperalgesia

99
Q

What has been shown to help with MS with central neuropathic pain?

A

Medical Marijuana

100
Q

Whats the MOA of muscle relaxants

A

Block transmission through the neuromuscular junction (NMJ) at nicotinic receptors, thus decreasing skeletal muscle tone

101
Q

What two meds will meet the criteria of conscious sedation?

A

Muscle relaxer and opiate

102
Q

Whats the s/e of cyclobenzaprine?

A

somnolence, dizziness, cognitive slowing.

103
Q

Which muscle relaxant lowers seizure threshold?

A

cyclobenzaprine

104
Q

Which muscle relaxant has less drowsiness?

A

Metaxalone

105
Q

Whats the S/e of carisoprodol?

A

ataxia, agitation, insomnia, tachycardia

106
Q

Which one is Subject to withdrawal symptoms and strong abuse potential, particularly when combined with an opioid?

A

Carisoprodol

107
Q

Why is Tramadol + Flexeril a NOO

A

Lowers seizure threshold

108
Q

Which one is LEAST sedating?

A

Methocarbamol

109
Q

When are muscle relaxant NOT SAFE?

A

pregnancy and lactation

110
Q

How long should you have pt on muscle relaxants?

A

Short course only

Clinical Pharm (8 decks)

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