MSK/Pain Flashcards
pharm options for MSK pain
NSAIDs
non-opioid analgesics
antiseizure
antidepressants
opioid analgesics
local anesthetics
5 invasive therapies for MSK pain
trigger point injxns
joint injxns
regional nerve blocks
epidural injxns
surgery
what pain med inhibits the synthesis of PG in the CNS
APAP
APAP works __ to block pain impulse generation
peripherally
does APAP inhibit platelets
not really
is APAP antiinflammatory
not really
when would you use 650 mg of APAP
arthritis
available doses for asa
81 mg - baby
325
500 mg - extra strength
650 mg - arthritis
what’s the max dose of APAP
4 g daily
what is the actual safest dose of apap
3
esp in elderly
apap is recommended for what uses
antipyretic
pain
-OA
-migraines
-MSK pain
-pregnant pain
antitode for apap
n-acetylcystine (mucomyst)
what pain med works by reducing PG and thromboxane A2 synthesis
salicylates - ASA
does asa inhibit platelet fxn
yes!
irreversibly fo’ life bro –> interferes w. hemostasis and prolongs bleeding time
use caution w. ASA in what 4 conditions
GI injury/upset
renal injury
viral syndromes in peds
asthma
risk of using ASA in viral syndrome w. peds
reye syndrome
how much ASA can precipitate an asthma attack in asa sensitive pt’s
single dose!
asa is mc recommended for what 3 conditions
anticoagulation
antipyresis
pain
-OA
-migraines
-MSK
non selective NSAIDs inhibit __ (2)
cox 1
cox 2
what are the non selective NSAIDs (6)
ibuprofen
naproxen/naproxen sodium
indomethacin
etodolac
diclofenac
sulindac
what is the only COX-2 inhibitor
celecoxib
only one!
NSAIDs are mc used for what conditions
antipyresis
anti-inflammatory
pain
-dysmenorrhea
-migraine/tension ha
-MSK pain/strain/sprain
NSAIDs are not recommended for what conditions (6)
fx pain
pregnancy
PUD
renal dysfxn
bleeding d.o
uncontrolled HTN
NSAIDs should be used but w. caution in (2)
current n/v
GERD
what is the topical NSAID
diclofenac sodium (voltaren gel)
is voltaern gel available OTC
yes
benefit of voltaren gel over orals
less s.e
topical anesthetics (2)
lidocaine - patches, gel, cream, spray
8% capsaicin patch (qutenza)
what has capsaicin patch (qutenza) been approved to treat
postherpetic neuralgia
parenteral NSAID
ketorolac (toradol)
mc at home dose of ASA
325 mg
t/f: all NSAIDs increase CV risk
t!
celecoxib has less __ side effects than non selective NSAIDs
GI
s.e of ketorolac (toradol)
aki
severe GI toxicity (particularly in elderly)
why doesn’t jaynstein like toradol
case reports of patients in every age group developing ARF after a single IM dose
per Jaynstein, max dose of toradol
30 mg
no benefit of going any higher
when can you give po toradol
only if it’s been given IV or IM first
toradol is mc recommended for
op relief of pain/inflammation from:
migraine
renal colic (but contraindicated in aki!)
what must you check before rx’ing toradol
renal fxn
s.e of nsaids (4)
exacebation/development of CHF
elevated bp/HTN
renal failure
hepatotoxicity
asthma exacerbation/anaphylaxis
platelet inhibition -> GIB, ulceration, perforation. PUD, etoh, advanced age
pt’s taking ASA for cardioprotection should not take __ bc it can interfere w. antiplatelet action
ibuprofen
asa __ inhibits platelets
ibuprofen __ inhibits platelets
asa: irreversibly
ibuprofen: reversibly
what 2 nsaids are used for chronic conditions to get pt’s off more commonly used ones
meloxicam
diclofenac
what does recent research show regarding cv risk w. celebrex
it’s prob about the same as other NSAIDs
antidote for nsaid toxicity
none!
6 strong opioids
fentanyl
hydromorphone
methadone
morphine
oxycodone
oxymorphone
3 weaker opioids
hydrocodone
codeine
tramadol
jaynsteins choices for opioids
- vicodin (hydrocodone + apap)
- percocet (oxycodone + apap)
do opioids have a ceiling for analgesic effects
no! they’ll just keep feeling better until they stop breathing
unlike nsaids
what 3 opioids contain apap
vicodin
vicoprofen
percocet
caution w. these
2 names for oxycodone
percocet
oxycontin
oxycodone is only available __
po
t/f: po oxycodone is more potent than oral morphine
t!
and oral codeine
what is jaynstein’s last line opioids choice
dilaudid
very coveted by people w. SUD
what increases release of fentanyl patches
heat
high fever
what must you do before prescribing fentanyl patch
d.c oral
and vice versa
fentanyl can become toxic when combined w. what drugs
CYP3A4 inhibitors -
ex ketoconazole (nizoral), clarithromycin (biaxin)
what 2 opioids does jaynstein hate bc some people don’t metabolize them and some people are super metabolizers
codeine
tramadon’t
vicodin, lortab, and norco are all
hydrocodone
why does jaynstein hate tramadol
8 black box warnings
it IS an opioid
lowers sz threshold
non metabolizers vs super metabolizers
associated w. withdrawal and overdoses
SSRI and SNRI activity –> many ddi’s
t/f: tramdol is associated w. fewer withdrawals and overdoses than other opioids
f!
adverse effects of opioids (8)
constipation
sedation
n/v
pruritis
hallucinations
confusion/delirium
myoclonic jerking
respiratory dpn
antidote for narcotics
naloxone (narcan)
do not go over __ mme’s when prescribing opioids
30
mainstay of tx for neuropathic pain syndromes
antidepressants
anticonvulsants
although most are not approved for these
antidepressants and anticonvulsants are commonly used to treat what 5 pain conditions
postherpetic neuralgia
diabetic neuropathy
fibromyalgia
complex regional pain syndrome
phantom limb syndrome
t/f: antidepressant/anticonvulsant combo increases analgesic effects
t!
name 3 TCAs
amitriptyline
nortriptyline
imipramine
TCAs are more effective than SSRIs for treating what type of pain
neuropathic
what SNRI has been shown to provide many analgesic benefits of older antidepressants but w. fewer side effects
duloxetine (cymbalta)
gabapentin is effective for what 2 types of pain
neuralgia
DM neuropathy
NO evidence for other types of pain
5 adverse effects of gabapentin
dizzy
somnolence
edema
wt gain
ABUSE!
pregabalin (lyrica) is approved for what 3 conditions
postherpetic neuralgia
DM neuropathy
fibromyalgia
s.e of pregabalin
same as gabapentin, but no abuse
what type of pain would you prescribe carbamazepine (anticonvulsant) for
trigeminal neuralgia
does jaynstein like lamotrigine
no!
recent studies have shown it’s less effective
can cause rash and SJS
what type of pain might you prescribe sodium valproate and topiramate for
migraine prophylaxis
what may enhance the analgesic effect of apap, ASA, or ibuprofen
caffeine
what may enhance analgesic effect of opioids in post op and cancer pain AND reduce n/v
hydralazine
what is the use of corticosteroids in adjuvant pain meds
may produce analgesia in inflammatory diseases or tumor infiltration of nerves
what alpha 2 agonist may improve pain and hyperalgesia
clonidine
medical marijuana has been shown to be effective for what 2 types of pain
MS
central neuropathic pain
moa for muscle relaxants
block transmission thru NMJ at nicotinic receptors -> decrease skeletal muscle tone
indication for muscle relaxants in MSK pain
only if spasms are present
jaynstein doesn’t really like
if you you have to prescribe, use short doses
what’s the problem w. prescribing muscle relaxants w. opioids
meets criteria for conscious sedation
which muscle relaxant causes the most somnolence, dizziness, and cognitive slowing
cyclobenzaprine (flexeril)
doesn’t really work - just causes pt’s to care less
flexeril (cyclobenzaprine) PLUS __ is a huge no bc it lowers sz threshold
tramadol
jaynstein’s 2 go to muscle relaxants
metaxalone (skelaxin)
baclofen
less drowsiness/cognitive effect
which muscle relaxant is associated w. ataxia, agitation, insomnia, tachycardia, and withdrawal symptoms
carisoprodol (soma)
only IV muscle relaxant
diazepam (valium)
high abuse potential
least sedating/cognitive effect muscle relaxer
methcarbamol (robaxin)
which muscle relaxants are safe for pregnant pt
none!
what are very efficacious drugs for chronic pain that are coming down the pipeline
methadone
suboxone
what 2 drugs should be first choice for all chronic pain
methadone
suboxone
what was our plan for 40 yo m w. chronic lb who failed supportive tx
lidocaine patches/voltaren gel
gabapentin
muscle relaxants should NOT be used for what type of pain
chronic
what was our plan for 56 yo f w. chronic pain syndrome on daily opiates and muscle relaxers
evaluate for suboxone/methadone MAT tx
what was our plan for the 30 yo f w. migraines w.o aura
menstrual migraines ->
nsaid dosing 2-3 days prior to menses
Mg
zomig (triptan)
jaynstein’s go to triptan
zomig
what 2 meds are associated w. best evidence for prevention of menses migraines
Mg
estrogen
