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Clin Pharm > MSK & Pain > Flashcards

MSK & Pain Flashcards

1
Q

4 goals of pain mgmt

A

↓ pain
↓ healthcare utilization
↑ functional status
↑ quality of life

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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

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3
Q

6 Pharm pain mgmt options

A

“NO ANAL”
*NSAIDS
*Opioid analgesics

*Anti-seizure medications
*Non-opioid analgesics
*Anti-depressants
*Local anesthetics

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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

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5
Q

APAP 1* MOA

A

Inhibit the syntheses of prostaglandins in the central nervous system

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6
Q

APAP other MOA

A

*Works peripherally to block pain impulse generation

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7
Q

Does APAP do anything for coag pathways?

A

No

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8
Q

Does APAP inhibit plt funciton?

A

*Poor inhibitor of platelet function

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9
Q

Does APAP exhibit anti-inflammatory properties

A

*Very little anti-inflammatory properties

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10
Q

Tylenol doses
Which is extra strength?
Which strength is for arthritis?

A

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

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11
Q

Max recommended dose APAP?

A

4g QD

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12
Q

Max recommended dose APAP elderly?

A

3g QD

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13
Q

APAP is mc rec for

A

Anti-pyresis

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14
Q

APAP relieves pain from (4):

A

“MOMS”
Migraine HA
OA
Muscle pain
Skeletal pn

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15
Q

Pain TOC for pregnant women?

A

APAP

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16
Q

Antidote for APAP

A

n-acetylcysteine

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17
Q

ASA 1* MOA

A

↓ prostaglandin and thromboxane A2 synthesis

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18
Q

Does ASA ↓ platelet aggregation

A

yes!

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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

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20
Q

ASA:
Caution with (3)

A

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

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21
Q

A single does of ___ can precipitate Asthma in ___ sensitive pts

A

ASA

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22
Q

ASA doses.
Which is MC home dose?
Extra strength?

A

81 (baby)
325mg (Home)
500mg (extra strength)

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23
Q

ASA MC recommended for:

A

Anti-coag

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24
Q

Which has better anti-pyresis:
ASA or APAP?

A

APAP

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25
Q

ASA relieves pain from:

A

“MOM”
Migraine
OA
Muscle pain

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26
Q

NSAIDS MOA:
Nonselective

A

Inhibit cox-1 and Cox-2

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27
Q

NSAIDS MOA:
Selective

A

Only inhibit COX-2

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28
Q

7 Nonselective NSAIDS

A

Non selective about dinner-“DINES IN”
Diclofenac
Ibuprofen
Naproxen
Etodolac
Sulindac
Indomethacin
Naproxen sodium

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29
Q

1 Selective NSAID

A

Celecoxib (COX-2)

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30
Q

T/F: Some pts may respond better to one NSAID than another

A

True

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31
Q

NSAIDs are MC recommended for:

A

Anti Pyresis

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32
Q

NSAIDs can relieve pain/inflammation from:

A

Dysmenorrhea
Migraine
Tension HA
Muscular pain
Tendionous pain
Sprain/Strain

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33
Q

T/F: NSAIDS can be used in pregnancy

A

NOope

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34
Q

How do NSAIDS decrease pain with menses?

A

NSAIDS slow down prostaglandin production→less uterine shedding→ fewer cramps & less bleeding

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35
Q

T/F: You can use NSAIDS after a fx to reduce pain

A

No! esp scaphoid fx and fx at risk for malunion

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36
Q

6 conditions you cannot use NSAIDs with:

A

Fracture pain
Pregnant women
Known history of PUD
Renal dysfunction
Bleeding disorders
Uncontrolled HTN

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37
Q

What 2 conditions can you use NSAIDS with caution

A

Current NV
GERD

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38
Q

T/F: Celebrex (Celocoxib) is the only NSAID to increase risk of CV events

A

ALL NSAIDS increase risk of CV events

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39
Q

Which NSAID has less GI s/e?

A

Celocoxib (Celebrex)

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40
Q

T/F: NSAIDS delay healing

A

True

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41
Q

Adverse Effects of NSAIDS
(AABCDEFGH)

A

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

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42
Q

How do NSAIDs cause renal failure or HTN?

A

↓ synthesis of renal vasodilator prostaglandins
and ↓ renal blood flow
→ fluid retention

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43
Q

Risk factors for Renal failure/HTN from NSAIDs

A

Advanced age
CHF
renal insufficiency
ascites
volume depletion
concurrent diuretic therapy

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44
Q

Be careful of ___Dz in NSAID use, ____ can occur

A

Liver Dz
Hepatotoxicity

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45
Q

Is NSAID inhibition of platelets reversible or irreversible?

A

Reversible

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46
Q

Risk factors for GI blee/ulcer/perf with NSAIDS
Can this occur with all NSAIDS?

A

High doses
Prolonged use
Previous PUD
Exceess ETOH
Advanced age

ALL NSAIDS

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47
Q

What med can interfere with antiplatelet action of ASA?

A

Ibuprofen

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48
Q

T/F: Pts taking ASA for CV protection can also take Ibuprofen regularly

A

NOPE!
WIll interfere with Antiplatelet action of ASA!
Not good

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49
Q

What are some chronic NSAIDs we can use instead of Ibuprofen

A

Indomethacin
Diclofenac
Meloxicam

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50
Q

NSAIDs:
Gout & pericarditis relief

A

Indomethacin

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51
Q

NSAIDS:
chronic pain relief in general

A

Diclofenac
Meloxicam

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52
Q

Dosing of NSAIDS

A

100-200mg BID

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53
Q

Does Celocoxib inhibit plt aggregation?

A

Nope (COX-1)

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54
Q

Does Celocoxib increase bleeding time?

A

Nope (COX-1)

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55
Q

Does Celocoxib given with warfarin, increase PT/INR

A

yes, a little

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56
Q

Does Celocoxib cause:
Exacerbation/Development of CHF
Renal Failure
HTN
Hepatotoxicity
Precipitate Asthma
Anahylaxis in ASA sensitive pts

A

yes

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57
Q

Morphine MME:
Vicodin

A

1:1

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58
Q

Morphine MME:
Fentanyl

A

1:7.2

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59
Q

Morphine MME:
Oxycodone

A

1:1.5

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60
Q

Is voltaren (diclofenac) 1% available OTC?

A

yes

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61
Q

T/F: Diclofenac has questionable fficacy

A

true

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62
Q

T/F: Diclofenac has a much safer profile than systemic NSAIDs

A

True

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63
Q

T/F: Diclofenac use is a contraindication to systemic NSAID use

A

false.
they can be taken concurrently if needed

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64
Q

Does lidocaine have decent effiacy?

A

yes

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65
Q

4 forms of lidocaine topcial

A

patches
gel
cream
spray

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66
Q

What is the approved tx for postherpetic neuralgia

A

Quetenza (8% capsacin patch)

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67
Q

3 NSAID that come in IV form

A

Tylenol
IBU
Toradol (NSAID)

68
Q

What is the MC used injectable NSAID

A

Toradol

69
Q

What NSAID is assoc w/AKI & Acute kidney failure & GI toxicity?

A

Toradol

70
Q

Toradol can cause Acute renal failure in ____ after ___ doses

A

peds to elderly
1 dose

71
Q

Can you use toradol in the elderly?

A

No

72
Q

There is _____ with increase in toradol dose (15 v 30 v 60 )
but there is _____

A

No additional analgesic benefit
longer lasting from higher dose

73
Q

What is toradol MC used for:
pain relief from:

A

** Renal colic!!! (beware of pts with renal disease/AKI)
Migraine

74
Q

if you have to give toradol to >65yo do this

A

reduce dose by 50%

75
Q

What is the antidote for NSAIDS?

A

None

76
Q

Which Narcotic has shortest action?

A

Fentanyl
Good for quick procedures

77
Q

Stronger Opioids (6)

A

Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone, Oxymorphone

78
Q

Weaker Opioids

A

Hydrocodone, Codeine, Tramadol

79
Q

Unlike NSAIDS, Opioids generally have no ___ for anagesic effectiveness except their _____

A

Ceiling
Adverse effects

80
Q

Use caution with Opioids combined with an ___ or ___
ie

A

APAP
NSAID
-Vicodin, Vicoprofen, Percocet

81
Q

Combined opioids:
___ is less potent than ____

A

Vicodin
Percocet

82
Q

Oxycodone:
_____ derivative of morphine
Only available in ___ formulation
_____ bioavailability
Half life _____

A

Semi Synthetic
PO
High bioavail
2.5-3hrs

83
Q

Oxycodone:
__ more potent than codeine
___ more potent than morphine

A

9.5x
1.5x

84
Q

High % of pop cannot convert codeine into active metabolite
What happens?

A

→Pts can either get no benefit or too much!!

85
Q

Hydromorphone (dilaudid)
___ formulations
Also in long or short acting ___ formulation

A

PO, IV, IM
PO

86
Q

When would you prefer hydromorphone (Dilaudid) to Morphine?
Why?

A

In patients with renal failure it may be preferred over morphine
- morphine has a risk of toxic metabolite accumulation

87
Q

Fentanyl
___ formualtions

A

IV
intrathecal
epidural
transdermal
oral transmucosal

88
Q

PO IR of Dilaudid (Hydromorphone):
Onset
Duration

A

30min
4hrs

89
Q

Fentanyl is ___x more potent than morphine

A

80x

90
Q

Fentanyl is very ___ so it binds ___ to plasma proteins

A

lipophilic
strongly

91
Q

Best formulation of fentantyl for chronic pain pts (diff swallowing or malabsorption)
Why?

A

Transdermal
more controlled release of drug (days)

92
Q

*** Exposig a fentanyl patch to ___ or ____ can ___ release of the drug

A

Heat
high Fever
increase release

93
Q

Use of fentanyl and which 2 drugs (inhibitors) can inhibit CYP3A4 & cause dangerous ___ of fentanyl

A

ketoconazole (Nizoral)
clarithromycin (Biaxin)

94
Q

Which formulation & name of fentanyl is approved for tx of breakthrough pain in CA?

A

Actiq (lozenge on a stick)

95
Q

4 other formulations of fentanyl for mgmt of breakthrough pain

A

buccal soluble film (Onsolis)
SL tablet (Abstral)
Nasal spray (Lazanda)
SL spray (Subsys)

96
Q

Codeine potency compared to morphine

A

50%

97
Q

Codeine /2 life

A

2.5-3hrs

98
Q

Codeine has a ____ metabolism

A

Uncontrolled metabolism
Some overconvert
Some cannot convert at all

99
Q

Lots of ___ with codeine

A

ADR’s
“BAD DRUG”

100
Q

Doses of codeine over 65mg are ____

A

not well tolerated

101
Q

T/F: Tramadol is an opiate

A

True

102
Q

Tramadol has 8 black box warnings
Name a few

A

*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
Q

Why does tramadol have more DDI’s than other opioids?

A

SSRI & SNRI activity
Inhibits both 5-HT and NE

104
Q

T/F: Tramadol is Associated with withdrawal and overdoses at comparable rates to other opiates

A

true

105
Q

T/F: Cannot have a sz after a single dose of Tramadol

A

false

106
Q

Tramadol MOA

A

Oral centrally-acting opioid agonist
binds to mu receptors blocking the reuptake of NE and 5-HT

107
Q

T/F: There is compelling evidence that tramadol works better than other opiates

A

False
none

108
Q

Jaynsteins summary for Tramadol:

A

Don’t give it

109
Q

Studies show NSAIDs & APAP are not inferior to tramadol

A

True

110
Q

Mgmt of adverse narcotic effects:
Constipation

A

Bowel regimen

111
Q

Mgmt of adverse narcotic effects:
Sedation

A

Tolerance typically develops.
Hold sedatives/anxiolytics
dose reduction
Consider CNS stinulants

112
Q

Mgmt of adverse narcotic effects:
NV

A

Dose reduction
opioid rotation
consider metoclopramide
prochlorperazine
scopolamine patch

113
Q

Mgmt of adverse narcotic effects:
pruritis

A

Dose reduction
opioid rotation
consider antihistamines or H2 blocker

114
Q

Mgmt of adverse narcotic effects:
hallucinations

A

Dose reduction
opioid rotation
consider Neuroleptic therapy (Haldol, Risperidone)

115
Q

Mgmt of adverse narcotic effects:
Confusion/delirium

A

Dose reduction
opioid rotation
consider Neuroleptic therapy (Haldol, Risperidone)

116
Q

Mgmt of adverse narcotic effects:
Myoclonic jerking

A

Dose reduction
opioid rotation
consider Clonazepam, Baclofen

117
Q

Mgmt of adverse narcotic effects:
Respiratory depression

A

Sedation precedes respiratory depression.
Hold opioid.
Give naloxone

118
Q

Before prescribing opioids
Use the ___

A

PDMP
if you have a DEA, its the law

119
Q

Antidepressants and anticonvulsants are the mainstay of treatment for a variety of _____

A

neuropathic Pain syndromes

120
Q

5 Neuropathic pain syndromes

A

Postherpetic neuralgia
Diabetic neuropathy
Fibromyalgia
Complex regional pain syndrome
phantom limb pain

121
Q

Combination use of _____ and _____medication may produce synergistic increases in analgesic effect in neuropathic pain syndromes.

A

Antideoressant
Anticonvulsant

122
Q

TCA’s relieve which 6 Neuropathic pains?

A

diabetic neuropathy
postherpetic neuralgia
polyneuropathy
fibromyalgia
nerve injury
infiltration with cancer

123
Q

___appear to be less effective than ____ for treatment of neuropathic pain

A

SSRIs
TCAs

124
Q

6 anticonvulsants

A

“Gaby & Val Like Carbamazepine to Prevent Trigeminal neuralgia”
Gabapentin (Neurotonin)
Pregabalin (Lyrica)
Carbamazepine
Lamotrigine (Lamectal)
Valporate (Depakote)
Topiramate (Topamax, etc)

125
Q

2 Neuropathic pains that Gabapentin (Neurontin) are effective for

A

Posteherpetic neuralgia
Diabetic Neuropathy

126
Q

T/F: Gabapentin (Neurontin) shows evidence for non-neuropathic pain

A

NO
(OVERPRESCR
IBED!)

127
Q

What is pregabalin (lyrica) good for?

A

**fibromyalgia
postherpetic neuralgia
diabetic peripheral neuropathy

128
Q

S/E of Gabapentin (Neurontin)

A

**Dizziness, **somnolence
edema
weight gain

129
Q

The dose of ___ can be titrated more rapidly than with ____

A

Lyrica
Gabapentin

130
Q

S/E of Pregabalin (Lyrica)

A

**Dizziness, **somnolence
peripheral edema
significant weight gain

131
Q

Which anticonvulsant is FDA approved for Tx of trigeminal neuralgia?

A

Carbamazepine

132
Q

Venlafaxine (Effexor) has been reported to be effective in _____pain and has also been used to treat

A

Neuropathic
HA, fibromyalgia and postmastectomy pain syndrome

133
Q

Does effexor have bad w/d symptoms

A

yes

134
Q

Duloxetine (Cymbalta) is approved for treatment of pain associated with ____ and ____

A

diabetic peripheral neuropathy and fibromyalgia

135
Q

Lamotrigine (Lamictal) was effective for _____pain and ______

A

Post CVA assoc pain
HIV-associated painful sensory neuropathies

136
Q

Lamotrigien can cause a __

A

Rash that can progress to SJS

137
Q

Sodium valproate (Depakote, and others) and topiramate (Topamax, and others) other use:
_____

A

Migraine prophylaxis

138
Q

Caffeine: Doses of 65-200 mg may _________of 3 rx:

A

enhance analgesic effect
acetaminophen, aspirin or ibuprofen.

139
Q

Hydroxyzine: Doses of 25-50 mg given parenterally may ______ of _____ in _____ and____pain while reducing the incidence of ___ and ___

A

enhance the analgesic effect
Opioids
Postoperative/ Cancer
NV

140
Q

Corticosteroids: Can provide ____ in some patients with ____ diseases or ____ infiltration of nerves.

A

analgesia
inflammatory
tumor

141
Q

Clonidine (Catapres) The ___ and _____ formulation of this ______may improve ___and ____

A

oral
tansdermal patch
Alpha 2 adrenergic agonist
pain & hyperalgesia

142
Q

***Medical marijuana has been shown to be effective in _____ with____

A

MS
Central neuropathic pain

143
Q

Muscle relaxants MOA

A

Block transmission through the neuromuscular junction (NMJ) at nicotinic receptors, thus
↓skeletal muscle tone→↓M spasm.

144
Q

Co-prescribing a ______ with an opiate meets the criteria of _______

A

Muscle relaxer
***Conscious ssedation

145
Q

MC Muscle relaxant

A

Cyclobenzaprine (FLexeril)

146
Q

Flexeril S/E (3):

A

causes the most somnolence, dizziness, cognitive slowing

147
Q
  • Flexeril can lower ____
A

Sz threshold

148
Q

***Never mix ___ with ____

A

Tramadol with Flexeril

149
Q

Why is Metazalone (Skelaxin) a better m relaxant? (2)

A

less drowsiness and cognitive effect,
associated with the least SEs

150
Q

S/E of Carisprodol (Soma)

A

ataxia, agitation, insomnia, tachycardia.

151
Q

What happens when we combine Carisprodol (Soma) with an Opiate?
What type of drug is this?

A

withdrawal symptoms and strong abuse potential

m relaxant

152
Q

What is the only IV option for M relaxant?

A

Diazepam (Valium)
Benzodiazepine

153
Q

Does Valium have a high abuse potential?

A

yes

154
Q

How does valium work?

A

Reflex spasms due to muscle or joint trauma or inflammation

155
Q

Which m relaxant is least sedating of the muscle relaxers and less cognitive effects

A

Methocarbamol (Robaxin)

156
Q

Which muscle relaxants are considered safe during pregnancy and lactation

A

** No muscle relaxants are considered safe during pregnancy and lactation

157
Q

The efficacy of muscle relaxants is____

A

Controvercial
– if you’re going to use, use short courses only

158
Q

How does Suboxone work

A

kicks off all opioids off Mu receptors- precipitates strong w/d!

159
Q

T/F: Methadone & Suboxone have:
Great efficacy for use in chronic pain
Longer acting

A

True

160
Q

Best pain options for pts who are taking too much APAP?

A

Topical options are best for this pt (voltaren)

161
Q

T/F: M. relaxants are NOT for chronic pain
ONLY for acute exacerbations of pain.

A

True

162
Q

60% of ___ with migraines have a correlation to ____.

A

women
menses

163
Q

Taking ___ for ___d before menses can help with ___AND ____

A

NSAIDs
2-3d
HA & cramps

164
Q

__ and __ demonstrate best evidence for menses migraine prevention.

A

Mg2+
Estrogen

165
Q

Which triptan is best for menstrual migraines?

A

Zomeg

166
Q

please differentiate between migraines with or w/o :

A

aura

Clin Pharm (6 decks)

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