MSK/Pain Management-Dobbs Flashcards
What are some goals of pain management therapy?
- decreased pain
- decreased healthcare utilization
- Improved functional status
- Improved QOL
List ex’s of non-pharmacologic pain treatment options
- Heat/cold
- Meditation/Relaxation
- Guided imagery
- Acupressure/acupuncture
- TENS units
- Physical Therapy
- Chiropractic Care
- Behavioral Therapy
- Cognitive/Behavioral Therapy
- Therapeutic Massage
List ex’s of pharmacologic pain treatment options
- NSAIDS
- Non-opioid analgesics
- Anti-seizure medications (gabapentin)
- Anti-depressants (amytriptiline)
- Opioid analgesics
- Local anesthetics
List ex’s of invasive therapies used for pain management
Trigger Point Injections
Joint Injections
Regional Nerve Blocks
Epidural Injection
Various Surgeries
Non-Opioid Analgesics: Acetaminophen (APAP)
-MOA ?
- Inhibits the syntheses of prostaglandins in the CNS
- Works peripherally to block pain impulse generation
Non-Opioid Analgesics: Acetaminophen (APAP)
- is a poor inhibitor of _____ function
- low or high anti-inflammatory properties?
- platelet function
- Very little anti-inflammatory properties
Acetaminophen (APAP, Tylenol):
- list the different strengths this med comes in
- Max recommended dose is ___ grams daily
- comes in 325 mg, 500 mg (extra strength), and 650 mg (arthritis)
- Max recommended dose= **4 grams daily
In elderly Pts, some clinicians have recommended lowering the max dosage of acetaminophen to __ grams daily
3
Acetaminophen (APAP) is MC recommended for anti-pyresis and relief of pain from: _______
Osteoarthritis Migraine headaches Skeletal pain Muscular pain Pain in pregnant women
Antidote for APAP?
N-acetylcystine (Mucomyst)
Non-Opioid Analgesics: Salicylates (Aspirin/ASA) MOA
-reduces prostaglandin and ________ synthesis
**thromboxane A2
Salicylates (Aspirin/ASA) MOA:
-reduces _________ aggregation
&
-irreversibly inhibits _______
- **platelet
- platelet function for the life of the platelet, interfering with hemostasis and prolonging bleeding time
When should you use Caution with ASA?
- GI tract injury/upset
- Renal injury
- Viral syndromes in children and teenagers–>risk of Reye’s syndrome
How many doses of ASA can precipitate asthma in aspirin-sensitive Pts?
a single dose
List different strengths ASA is available in
81mg (baby), 325mg, 500mg (Extra-strength
Salicylates (Aspirin/ASA) are MC recommended for: _________
Anti-coagulation Anti-pyresis Relief of pain from: Osteoarthritis Migraine headaches Muscular pain
list ex’s of Non-selective NSAIDs
Ibuprofen Naproxen Naproxen sodium Indomethacin Etodolac Diclofenac Sulindac
List an example of a Selective NSAID
Celcoxib**
T/F: some patients may respond better to one NSAID than another
true!
When are NSAIDs contraindicated?
DO NOT use NSAIDs with fractures– this can delay bone healing
NSAIDs are MC recommended for anti-pyresis and relief of pain/inflammation from: _________
- Dysmenorrhea
- Migraine/tension headaches
- Muscular/tendinous pain/strain/sprain
NSAIDs are NOT recommended for use with: ___________
Fracture pain Pregnant women Known history of PUD Renal dysfunction Bleeding disorders Uncontrolled HTN
NSAIDs should be used with caution in: ________
- Current nausea/vomiting
- GERD
Parenteral NSAIDs:
- how often is Ketorolac (toradol) used?
- How long do the effects last?
- MC used injectable
- short-term (up to 5 days)
Ketorolac (toradol):
-list ADRs
-Severe GI toxicity can still occur, particularly in the elderly
What IV med was recently approved by the FDA for use in children, 6 months and older, and adults and is being marketed as an antipyretic and as an analgesic for moderate to severe pain, either alone or in conjunction with opioid therapy?
Intravenous ibuprofen (Caldolor)
Ketorolac(torodol) is hard on the kidneys so follow a ketorolac injection with _________
acetaminophen
There are case reports of patients in EVERY age group – pediatric to elderly – developing ________ after a single dose of Toradol IM
- *acute renal failure
- **There is NO additional analgesic benefit to giving 60 vs. 30 mg of Toradol - the 60 mg dosage only lasts longer
High risk Pts for Toradol are generally >___yo
> 65, with known vascular or renal disease. Dosage should be adjusted downward 50%, if given at all.
Toradol is MC recommended for Outpatient relief of pain/inflammation from:
- Migraine headaches
- Severe pain
Adverse Effects of Non-Selective NSAIDs (list)
- Exacerbation or development of CHF
- Increased BP
- Can precipitate asthma and anaphylactoid rxn in aspirin-sensitive patients
- Reversible inhibition of platelet aggregation
NSAIDs decrease synthesis of renal vasodilator prostaglandins and decrease renal blood flow, which can lead to _______
- *fluid retention and may cause renal failure or HTN
- Risk factors include: advanced age, CHF, renal insufficiency, ascites, volume depletion and concurrent diuretic therapy
- **Hepatotoxicity can occur
Adverse Effects of Non-Selective NSAIDs cont:
-GI bleeding, ulceration and perforation can occur with all of these drugs. High doses, prolonged use, previous peptic ulcer disease, excessive alcohol intake and advanced age increase the risk of these complications—> make sure to add a ____
**PPI
Aspirin for CV protection should not take _______ regularly
ibuprofen.*** must take ibuprofen 2 hrs after taking aspirin
**Ibuprofen can interfere with the anti-platelet effect of aspirin
Ibuprofen:
- dosage forms ?
- Dose frequency?
- Max dose?
- 400 mg of ibuprofen is comparable to ______
- 200, 400, 600, 800
- usual dose 200-600mg
- Q4-6hrs
- max dose of 2400 OR (3200 if using 800 mg Q8hrs)
-**400 mg is comparable to APAP/Codeine; combo with pepcid
Naproxen:
- dosage forms ?
- Dose frequency?
- Max dose?
- Available in which forms?
- 250, 375, 500, (usual is 250 (500))
- Q6-8 hrs, (or Q12 hrs if using 500mg)
- Max dose= 1000mg
- available in CR and enteric coated, fixed dose with PPI (vimovo)
Naproxen Sodium:
- dosage forms ?
- Dose frequency?
- Max dose?
- OTC formulation= ?
- 220,550
- Q6-8hrs (Q12 hrs if using 550mg)
- Max dose= 1100
- OTC aleve= naproxen
NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)
-dosing?
100 – 200 mg BID
NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)
- list adverse effects (pros and cons of celebrex)
- what happens if Celebrex is given with Warfarin?
- Celecoxib appears to cause **less GI toxicity than non-selective NSAIDs
- Other adverse effects are similar to those of non-selective NSAIDs but increased MI and CVA risk.
- Celecoxib does NOT inhibit platelet aggregation or increase bleeding time
-If given with warfarin, it may increase INR/PT, but the effect is unlikely to be clinically significant.
Antidote for NSAIDs?
none
Opioid morphine equivalents:
- codeine: morphine?
- Fentanyl patch: morphine?
1: 0.15
1: 7.2
Opioid morphine equivalents:
- Hydrocodone: morphine?
- Hydromorphone: morphine?
- 1:1
- 1:4
Opioid morphine equivalents:
- methadone: morphine?
- opium:morphine
- 1:3
- 1:1
Opioid morphine equivalents:
- opium?
- oxycodone?
- tramadol?
- 1:1
- 1:1.5
1: 0.1
List ex’s of stronger opioids
Fentanyl, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone