MSK & Pain Flashcards
1
Q
4 goals of pain mgmt
A
↓ pain
↓ healthcare utilization
↑ functional status
↑ quality of life
2
Q
10 Non-pharm pain mgmt options
A
***Heat/cold
Acute MSK Inj- ice 24-48hrs
* Meditation/Relaxation
*Guided imagery
*Acupressure/acupuncture
*TENS units
not during acute pain
*Physical Therapy
*Chiropractic Care
Behavioral Therapy
**We should use this more
*Cognitive/Behavioral Therapy
*Therapeutic Massage
3
Q
6 Pharm pain mgmt options
A
“NO ANAL”
*NSAIDS
*Opioid analgesics
*Anti-seizure medications
*Non-opioid analgesics
*Anti-depressants
*Local anesthetics
4
Q
Invasive therapies for Pain mgmt
A
***Trigger Point Injections
good for focal pain!!!
Not super invasive!
*Joint Injections
we don’t do these in ER for pain control.
Lots of PCPs do- it’s a good idea!
*Regional Nerve Blocks
we will be better at these than providers before us!
*Epidural Injection
later line
*Various Surgeries
5
Q
APAP 1* MOA
A
Inhibit the syntheses of prostaglandins in the central nervous system
6
Q
APAP other MOA
A
*Works peripherally to block pain impulse generation
7
Q
Does APAP do anything for coag pathways?
A
No
8
Q
Does APAP inhibit plt funciton?
A
*Poor inhibitor of platelet function
9
Q
Does APAP exhibit anti-inflammatory properties
A
*Very little anti-inflammatory properties
10
Q
Tylenol doses
Which is extra strength?
Which strength is for arthritis?
A
325mg
500mg (Extra Strength)
650mg (Arthritis)
11
Q
Max recommended dose APAP?
A
4g QD
12
Q
Max recommended dose APAP elderly?
A
3g QD
13
Q
APAP is mc rec for
A
Anti-pyresis
14
Q
APAP relieves pain from (4):
A
“MOMS”
Migraine HA
OA
Muscle pain
Skeletal pn
15
Q
Pain TOC for pregnant women?
A
APAP
16
Q
Antidote for APAP
A
n-acetylcysteine
17
Q
ASA 1* MOA
A
↓ prostaglandin and thromboxane A2 synthesis
18
Q
Does ASA ↓ platelet aggregation
A
yes!
19
Q
How does ASA inhibit plt function?
A
Irreversibly inhibits platelet function for the life of the platelet, interfering with hemostasis and prolonging bleeding time
20
Q
ASA:
Caution with (3)
A
Gastrointestinal tract injury/upset
Renal injury
Viral syndromes in children and teenagers
-risk of Reye syndrome
21
Q
A single does of ___ can precipitate Asthma in ___ sensitive pts
A
ASA
22
Q
ASA doses.
Which is MC home dose?
Extra strength?
A
81 (baby)
325mg (Home)
500mg (extra strength)
23
Q
ASA MC recommended for:
A
Anti-coag
24
Q
Which has better anti-pyresis:
ASA or APAP?
A
APAP
25
ASA relieves pain from:
"MOM"
Migraine
OA
Muscle pain
26
NSAIDS MOA:
Nonselective
Inhibit cox-1 and Cox-2
27
NSAIDS MOA:
Selective
Only inhibit COX-2
28
7 Nonselective NSAIDS
Non selective about dinner-"DINES IN"
Diclofenac
Ibuprofen
Naproxen
Etodolac
Sulindac
Indomethacin
Naproxen sodium
29
1 Selective NSAID
Celecoxib (COX-2)
30
T/F: Some pts may respond better to one NSAID than another
True
31
NSAIDs are MC recommended for:
Anti Pyresis
32
NSAIDs can relieve pain/inflammation from:
Dysmenorrhea
Migraine
Tension HA
Muscular pain
Tendionous pain
Sprain/Strain
33
T/F: NSAIDS can be used in pregnancy
NOope
34
How do NSAIDS decrease pain with menses?
NSAIDS slow down prostaglandin production→less uterine shedding→ fewer cramps & less bleeding
35
T/F: You can use NSAIDS after a fx to reduce pain
No! esp scaphoid fx and fx at risk for malunion
36
6 conditions you cannot use NSAIDs with:
Fracture pain
Pregnant women
Known history of PUD
Renal dysfunction
Bleeding disorders
Uncontrolled HTN
37
What 2 conditions can you use NSAIDS with caution
Current NV
GERD
38
T/F: Celebrex (Celocoxib) is the only NSAID to increase risk of CV events
ALL NSAIDS increase risk of CV events
39
Which NSAID has less GI s/e?
Celocoxib (Celebrex)
40
T/F: NSAIDS delay healing
True
41
Adverse Effects of NSAIDS
(AABCDEFGH)
AA- anaphylaxis in ASA sensitive pts & Asthma precipitation
B- BP (HTN)
C- Coag probs (inhibit plts)
D- DM and renal failure (Naproxen)
E- Exacerbate CHF
F- failure of kidneys
G- GI bleed/ulcers/perforation
H- Hepatotoxicity
42
How do NSAIDs cause renal failure or HTN?
↓ synthesis of renal vasodilator prostaglandins
and ↓ renal blood flow
→ fluid retention
43
Risk factors for Renal failure/HTN from NSAIDs
Advanced age
CHF
renal insufficiency
ascites
volume depletion
concurrent diuretic therapy
44
Be careful of ___Dz in NSAID use, ____ can occur
Liver Dz
Hepatotoxicity
45
Is NSAID inhibition of platelets reversible or irreversible?
Reversible
46
Risk factors for GI blee/ulcer/perf with NSAIDS
Can this occur with all NSAIDS?
High doses
Prolonged use
Previous PUD
Exceess ETOH
Advanced age
ALL NSAIDS
47
What med can interfere with antiplatelet action of ASA?
Ibuprofen
48
T/F: Pts taking ASA for CV protection can also take Ibuprofen regularly
NOPE!
WIll interfere with Antiplatelet action of ASA!
Not good
49
What are some chronic NSAIDs we can use instead of Ibuprofen
Indomethacin
Diclofenac
Meloxicam
50
NSAIDs:
Gout & pericarditis relief
Indomethacin
51
NSAIDS:
chronic pain relief in general
Diclofenac
Meloxicam
52
Dosing of NSAIDS
100-200mg BID
53
Does Celocoxib inhibit plt aggregation?
Nope (COX-1)
54
Does Celocoxib increase bleeding time?
Nope (COX-1)
55
Does Celocoxib given with warfarin, increase PT/INR
yes, a little
56
Does Celocoxib cause:
Exacerbation/Development of CHF
Renal Failure
HTN
Hepatotoxicity
Precipitate Asthma
Anahylaxis in ASA sensitive pts
yes
57
Morphine MME:
Vicodin
1:1
58
Morphine MME:
Fentanyl
1:7.2
59
Morphine MME:
Oxycodone
1:1.5
60
Is voltaren (diclofenac) 1% available OTC?
yes
61
T/F: Diclofenac has questionable fficacy
true
62
T/F: Diclofenac has a much safer profile than systemic NSAIDs
True
63
T/F: Diclofenac use is a contraindication to systemic NSAID use
false.
they can be taken concurrently if needed
64
Does lidocaine have decent effiacy?
yes
65
4 forms of lidocaine topcial
patches
gel
cream
spray
66
What is the approved tx for postherpetic neuralgia
Quetenza (8% capsacin patch)
67
3 NSAID that come in IV form
Tylenol
IBU
Toradol (NSAID)
68
What is the MC used injectable NSAID
Toradol
69
What NSAID is assoc w/AKI & Acute kidney failure & GI toxicity?
Toradol
70
Toradol can cause Acute renal failure in ____ after ___ doses
peds to elderly
1 dose
71
Can you use toradol in the elderly?
No
72
There is _____ with increase in toradol dose (15 v 30 v 60 )
but there is _____
No additional analgesic benefit
longer lasting from higher dose
73
What is toradol MC used for:
pain relief from:
** Renal colic!!! (beware of pts with renal disease/AKI)
Migraine
74
if you have to give toradol to >65yo do this
reduce dose by 50%
75
What is the antidote for NSAIDS?
None
76
Which Narcotic has shortest action?
Fentanyl
Good for quick procedures
77
Stronger Opioids (6)
Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone, Oxymorphone
78
Weaker Opioids
Hydrocodone, Codeine, Tramadol
79
Unlike NSAIDS, Opioids generally have no ___ for anagesic effectiveness except their _____
Ceiling
Adverse effects
80
Use caution with Opioids combined with an ___ or ___
ie
APAP
NSAID
-Vicodin, Vicoprofen, Percocet
81
Combined opioids:
___ is less potent than ____
Vicodin
Percocet
82
Oxycodone:
_____ derivative of morphine
Only available in ___ formulation
_____ bioavailability
Half life _____
Semi Synthetic
PO
High bioavail
2.5-3hrs
83
Oxycodone:
__ more potent than codeine
___ more potent than morphine
9.5x
1.5x
84
High % of pop cannot convert codeine into active metabolite
What happens?
→Pts can either get no benefit or too much!!
85
Hydromorphone (dilaudid)
___ formulations
Also in long or short acting ___ formulation
PO, IV, IM
PO
86
When would you prefer hydromorphone (Dilaudid) to Morphine?
Why?
In patients with renal failure it may be preferred over morphine
- morphine has a risk of toxic metabolite accumulation
87
Fentanyl
___ formualtions
IV
intrathecal
epidural
transdermal
oral transmucosal
88
PO IR of Dilaudid (Hydromorphone):
Onset
Duration
30min
4hrs
89
Fentanyl is ___x more potent than morphine
80x
90
Fentanyl is very ___ so it binds ___ to plasma proteins
lipophilic
strongly
91
Best formulation of fentantyl for chronic pain pts (diff swallowing or malabsorption)
Why?
Transdermal
more controlled release of drug (days)
92
*** Exposig a fentanyl patch to ___ or ____ can ___ release of the drug
Heat
high Fever
increase release
93
Use of fentanyl and which 2 drugs (inhibitors) can inhibit CYP3A4 & cause dangerous ___ of fentanyl
ketoconazole (Nizoral)
clarithromycin (Biaxin)
94
Which formulation & name of fentanyl is approved for tx of breakthrough pain in CA?
Actiq (lozenge on a stick)
95
4 other formulations of fentanyl for mgmt of breakthrough pain
buccal soluble film (Onsolis)
SL tablet (Abstral)
Nasal spray (Lazanda)
SL spray (Subsys)
96
Codeine potency compared to morphine
50%
97
Codeine /2 life
2.5-3hrs
98
Codeine has a ____ metabolism
Uncontrolled metabolism
Some overconvert
Some cannot convert at all
99
Lots of ___ with codeine
ADR's
"BAD DRUG"
100
Doses of codeine over 65mg are ____
not well tolerated
101
T/F: Tramadol is an opiate
True
102
Tramadol has 8 black box warnings
Name a few
*P450 metabolism- 10% of whites have 0 response & 2-5% of pts are hypermetabolizers
*Lowers sz threshold
*Prolonged QT
*Resp depression comp to opioids
DDI's
103
Why does tramadol have more DDI's than other opioids?
SSRI & SNRI activity
Inhibits both 5-HT and NE
104
T/F: Tramadol is Associated with withdrawal and overdoses at comparable rates to other opiates
true
105
T/F: Cannot have a sz after a single dose of Tramadol
false
106
Tramadol MOA
Oral centrally-acting opioid agonist
binds to mu receptors blocking the reuptake of NE and 5-HT
107
T/F: There is compelling evidence that tramadol works better than other opiates
False
none
108
Jaynsteins summary for Tramadol:
Don't give it
109
Studies show NSAIDs & APAP are not inferior to tramadol
True
110
Mgmt of adverse narcotic effects:
Constipation
Bowel regimen
111
Mgmt of adverse narcotic effects:
Sedation
Tolerance typically develops.
Hold sedatives/anxiolytics
dose reduction
Consider CNS stinulants
112
Mgmt of adverse narcotic effects:
NV
Dose reduction
opioid rotation
consider metoclopramide
prochlorperazine
scopolamine patch
113
Mgmt of adverse narcotic effects:
pruritis
Dose reduction
opioid rotation
consider antihistamines or H2 blocker
114
Mgmt of adverse narcotic effects:
hallucinations
Dose reduction
opioid rotation
consider Neuroleptic therapy (Haldol, Risperidone)
115
Mgmt of adverse narcotic effects:
Confusion/delirium
Dose reduction
opioid rotation
consider Neuroleptic therapy (Haldol, Risperidone)
116
Mgmt of adverse narcotic effects:
Myoclonic jerking
Dose reduction
opioid rotation
consider Clonazepam, Baclofen
117
Mgmt of adverse narcotic effects:
Respiratory depression
Sedation precedes respiratory depression.
Hold opioid.
Give naloxone
118
Before prescribing opioids
Use the ___
PDMP
if you have a DEA, its the law
119
Antidepressants and anticonvulsants are the mainstay of treatment for a variety of _____
neuropathic Pain syndromes
120
5 Neuropathic pain syndromes
Postherpetic neuralgia
Diabetic neuropathy
Fibromyalgia
Complex regional pain syndrome
phantom limb pain
121
Combination use of _____ and _____medication may produce synergistic increases in analgesic effect in neuropathic pain syndromes.
Antideoressant
Anticonvulsant
122
TCA's relieve which 6 Neuropathic pains?
diabetic neuropathy
postherpetic neuralgia
polyneuropathy
fibromyalgia
nerve injury
infiltration with cancer
123
___appear to be less effective than ____ for treatment of neuropathic pain
SSRIs
TCAs
124
6 anticonvulsants
"Gaby & Val Like Carbamazepine to Prevent Trigeminal neuralgia"
Gabapentin (Neurotonin)
Pregabalin (Lyrica)
Carbamazepine
Lamotrigine (Lamectal)
Valporate (Depakote)
Topiramate (Topamax, etc)
125
2 Neuropathic pains that Gabapentin (Neurontin) are effective for
Posteherpetic neuralgia
Diabetic Neuropathy
126
T/F: Gabapentin (Neurontin) shows evidence for non-neuropathic pain
NO
(OVERPRESCR
IBED!)
127
What is pregabalin (lyrica) good for?
**fibromyalgia
postherpetic neuralgia
diabetic peripheral neuropathy
128
S/E of Gabapentin (Neurontin)
**Dizziness, **somnolence
edema
weight gain
129
The dose of ___ can be titrated more rapidly than with ____
Lyrica
Gabapentin
130
S/E of Pregabalin (Lyrica)
**Dizziness, **somnolence
peripheral edema
significant weight gain
131
Which anticonvulsant is FDA approved for Tx of trigeminal neuralgia?
Carbamazepine
132
Venlafaxine (Effexor) has been reported to be effective in _____pain and has also been used to treat
Neuropathic
HA, fibromyalgia and postmastectomy pain syndrome
133
Does effexor have bad w/d symptoms
yes
134
Duloxetine (Cymbalta) is approved for treatment of pain associated with ____ and ____
diabetic peripheral neuropathy and fibromyalgia
135
Lamotrigine (Lamictal) was effective for _____pain and ______
Post CVA assoc pain
HIV-associated painful sensory neuropathies
136
Lamotrigien can cause a __
Rash that can progress to SJS
137
Sodium valproate (Depakote, and others) and topiramate (Topamax, and others) other use:
_____
Migraine prophylaxis
138
Caffeine: Doses of 65-200 mg may _________of 3 rx:
enhance analgesic effect
acetaminophen, aspirin or ibuprofen.
139
Hydroxyzine: Doses of 25-50 mg given parenterally may ______ of _____ in _____ and____pain while reducing the incidence of ___ and ___
enhance the analgesic effect
Opioids
Postoperative/ Cancer
NV
140
Corticosteroids: Can provide ____ in some patients with ____ diseases or ____ infiltration of nerves.
analgesia
inflammatory
tumor
141
Clonidine (Catapres) The ___ and _____ formulation of this ______may improve ___and ____
oral
tansdermal patch
Alpha 2 adrenergic agonist
pain & hyperalgesia
142
***Medical marijuana has been shown to be effective in _____ with____
MS
Central neuropathic pain
143
Muscle relaxants MOA
Block transmission through the neuromuscular junction (NMJ) at nicotinic receptors, thus
↓skeletal muscle tone→↓M spasm.
144
Co-prescribing a ______ with an opiate meets the criteria of _______
Muscle relaxer
***Conscious ssedation
145
MC Muscle relaxant
Cyclobenzaprine (FLexeril)
146
Flexeril S/E (3):
causes the most somnolence, dizziness, cognitive slowing
147
* Flexeril can lower ____
Sz threshold
148
***Never mix ___ with ____
Tramadol with Flexeril
149
Why is Metazalone (Skelaxin) a better m relaxant? (2)
less drowsiness and cognitive effect,
associated with the least SEs
150
S/E of Carisprodol (Soma)
ataxia, agitation, insomnia, tachycardia.
151
What happens when we combine Carisprodol (Soma) with an Opiate?
What type of drug is this?
withdrawal symptoms and strong abuse potential
m relaxant
152
What is the only IV option for M relaxant?
Diazepam (Valium)
Benzodiazepine
153
Does Valium have a high abuse potential?
yes
154
How does valium work?
Reflex spasms due to muscle or joint trauma or inflammation
155
Which m relaxant is least sedating of the muscle relaxers and less cognitive effects
Methocarbamol (Robaxin)
156
Which muscle relaxants are considered safe during pregnancy and lactation
** No muscle relaxants are considered safe during pregnancy and lactation
157
The efficacy of muscle relaxants is____
Controvercial
– if you’re going to use, use short courses only
158
How does Suboxone work
kicks off all opioids off Mu receptors- precipitates strong w/d!
159
T/F: Methadone & Suboxone have:
Great efficacy for use in chronic pain
Longer acting
True
160
Best pain options for pts who are taking too much APAP?
Topical options are best for this pt (voltaren)
161
T/F: M. relaxants are NOT for chronic pain
ONLY for acute exacerbations of pain.
True
162
60% of ___ with migraines have a correlation to ____.
women
menses
163
Taking ___ for ___d before menses can help with ___AND ____
NSAIDs
2-3d
HA & cramps
164
__ and __ demonstrate best evidence for menses migraine prevention.
Mg2+
Estrogen
165
Which triptan is best for menstrual migraines?
Zomeg
166
please differentiate between migraines with or w/o :
aura
