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Pharmacotherapeutics - Fall 21 > MSK/Pain Management-Dobbs > Flashcards

MSK/Pain Management-Dobbs Flashcards

1
Q

What are some goals of pain management therapy?

A
  • decreased pain
  • decreased healthcare utilization
  • Improved functional status
  • Improved QOL
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2
Q

List ex’s of non-pharmacologic pain treatment options

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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3
Q

List ex’s of pharmacologic pain treatment options

A
  • NSAIDS
  • Non-opioid analgesics
  • Anti-seizure medications (gabapentin)
  • Anti-depressants (amytriptiline)
  • Opioid analgesics
  • Local anesthetics
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4
Q

List ex’s of invasive therapies used for pain management

A

Trigger Point Injections

Joint Injections

Regional Nerve Blocks

Epidural Injection

Various Surgeries

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5
Q

Non-Opioid Analgesics: Acetaminophen (APAP)

-MOA ?

A
  • Inhibits the syntheses of prostaglandins in the CNS

- Works peripherally to block pain impulse generation

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6
Q

Non-Opioid Analgesics: Acetaminophen (APAP)

  • is a poor inhibitor of _____ function
  • low or high anti-inflammatory properties?
A
  • platelet function

- Very little anti-inflammatory properties

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7
Q

Acetaminophen (APAP, Tylenol):

  • list the different strengths this med comes in
  • Max recommended dose is ___ grams daily
A
  • comes in 325 mg, 500 mg (extra strength), and 650 mg (arthritis)
  • Max recommended dose= **4 grams daily
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8
Q

In elderly Pts, some clinicians have recommended lowering the max dosage of acetaminophen to __ grams daily

A

3

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9
Q

Acetaminophen (APAP) is MC recommended for anti-pyresis and relief of pain from: _______

A 
Osteoarthritis
Migraine headaches
Skeletal pain
Muscular pain
Pain in pregnant women
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10
Q

Antidote for APAP?

A

N-acetylcystine (Mucomyst)

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11
Q

Non-Opioid Analgesics: Salicylates (Aspirin/ASA) MOA

-reduces prostaglandin and ________ synthesis

A

**thromboxane A2

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12
Q

Salicylates (Aspirin/ASA) MOA:
-reduces _________ aggregation
&
-irreversibly inhibits _______

A
  • **platelet

- platelet function for the life of the platelet, interfering with hemostasis and prolonging bleeding time

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13
Q

When should you use Caution with ASA?

A
  • GI tract injury/upset
  • Renal injury
  • Viral syndromes in children and teenagers–>risk of Reye’s syndrome
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14
Q

How many doses of ASA can precipitate asthma in aspirin-sensitive Pts?

A

a single dose

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15
Q

List different strengths ASA is available in

A

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

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16
Q

Salicylates (Aspirin/ASA) are MC recommended for: _________

A 
Anti-coagulation
Anti-pyresis
Relief of pain from:
Osteoarthritis
Migraine headaches
Muscular pain
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17
Q

list ex’s of Non-selective NSAIDs

A 
Ibuprofen
Naproxen 
Naproxen sodium 
Indomethacin
Etodolac
Diclofenac
Sulindac
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18
Q

List an example of a Selective NSAID

A

Celcoxib**

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19
Q

T/F: some patients may respond better to one NSAID than another

A

true!

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20
Q

When are NSAIDs contraindicated?

A

DO NOT use NSAIDs with fractures– this can delay bone healing

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21
Q

NSAIDs are MC recommended for anti-pyresis and relief of pain/inflammation from: _________

A
  • Dysmenorrhea
  • Migraine/tension headaches
  • Muscular/tendinous pain/strain/sprain
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22
Q

NSAIDs are NOT recommended for use with: ___________

A 
Fracture pain
Pregnant women
Known history of PUD
Renal dysfunction
Bleeding disorders
Uncontrolled HTN
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23
Q

NSAIDs should be used with caution in: ________

A
  • Current nausea/vomiting

- GERD

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24
Q

Parenteral NSAIDs:

  • how often is Ketorolac (toradol) used?
  • How long do the effects last?
A
  • MC used injectable

- short-term (up to 5 days)

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25
Q

Ketorolac (toradol):

-list ADRs

A

-Severe GI toxicity can still occur, particularly in the elderly

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26
Q

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?

A

Intravenous ibuprofen (Caldolor)

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27
Q

Ketorolac(torodol) is hard on the kidneys so follow a ketorolac injection with _________

A

acetaminophen

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28
Q

There are case reports of patients in EVERY age group – pediatric to elderly – developing ________ after a single dose of Toradol IM

A
  • *acute renal failure

- **There is NO additional analgesic benefit to giving 60 vs. 30 mg of Toradol - the 60 mg dosage only lasts longer

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29
Q

High risk Pts for Toradol are generally >___yo

A

> 65, with known vascular or renal disease. Dosage should be adjusted downward 50%, if given at all.

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30
Q

Toradol is MC recommended for Outpatient relief of pain/inflammation from:

A
  • Migraine headaches

- Severe pain

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31
Q

Adverse Effects of Non-Selective NSAIDs (list)

A
  • Exacerbation or development of CHF
  • Increased BP
  • Can precipitate asthma and anaphylactoid rxn in aspirin-sensitive patients
  • Reversible inhibition of platelet aggregation
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32
Q

NSAIDs decrease synthesis of renal vasodilator prostaglandins and decrease renal blood flow, which can lead to _______

A
  • *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
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33
Q

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 ____

A

**PPI

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34
Q

Aspirin for CV protection should not take _______ regularly

A

ibuprofen.*** must take ibuprofen 2 hrs after taking aspirin

**Ibuprofen can interfere with the anti-platelet effect of aspirin

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35
Q

Ibuprofen:

  • dosage forms ?
  • Dose frequency?
  • Max dose?
  • 400 mg of ibuprofen is comparable to ______
A
  • 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

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36
Q

Naproxen:

  • dosage forms ?
  • Dose frequency?
  • Max dose?
  • Available in which forms?
A
  • 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)
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37
Q

Naproxen Sodium:

  • dosage forms ?
  • Dose frequency?
  • Max dose?
  • OTC formulation= ?
A
  • 220,550
  • Q6-8hrs (Q12 hrs if using 550mg)
  • Max dose= 1100
  • OTC aleve= naproxen
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38
Q

NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)

-dosing?

A

100 – 200 mg BID

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39
Q

NSAID Analgesics:Selective COX-2 Inhibitors (Celebrex)

  • list adverse effects (pros and cons of celebrex)
  • what happens if Celebrex is given with Warfarin?
A
  • 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.

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40
Q

Antidote for NSAIDs?

A

none

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41
Q

Opioid morphine equivalents:

  • codeine: morphine?
  • Fentanyl patch: morphine?
A

1: 0.15
1: 7.2

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42
Q

Opioid morphine equivalents:

  • Hydrocodone: morphine?
  • Hydromorphone: morphine?
A
  • 1:1

- 1:4

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43
Q

Opioid morphine equivalents:

  • methadone: morphine?
  • opium:morphine
A
  • 1:3

- 1:1

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44
Q

Opioid morphine equivalents:

  • opium?
  • oxycodone?
  • tramadol?
A
  • 1:1
  • 1:1.5
    1: 0.1
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45
Q

List ex’s of stronger opioids

A

Fentanyl, Hydromorphone, Levorphanol, Meperidine, Methadone, Morphine, Oxycodone, Oxymorphone

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46
Q

List ex’s of weaker opioids

A

Hydrocodone, Codeine, Tramadol

47
Q

Unlike NSAIDs, opioids generally have no ________

A

**ceiling for their analgesic effectiveness, except that imposed by adverse effects

48
Q

Caution with opioids combined with _____ or ____

A

APAP or an NSAID (Vicodin, Vicoprofen, Percocet)

49
Q

Oxycodone:

  • brand names?
  • available in which forms?
  • bioavailability?
A
  • (Percocet, OxyContin), a semi-synthetic derivative of morphine, is only available in oral formulations
  • Bioavailability of oxy is **high in oral dosage, with a half-life of 2.5 to 3 hours
50
Q

Oral Oxycodone is about ____x more potent than oral codeine and 1.5x more potent than oral morphine

51
Q

Hydromorphone:

  • brand names?
  • formulations?
  • What Pt population is hydromorphine preferred over morphine?
A
  • Dilaudid, and others, available in parenteral (IV, IM, SubQ), rectal and short- and long-acting oral formulations
  • **In Pts w/ renal failure it may be preferred over morphine (with morphine’s risk of toxic metabolite accumulation).
52
Q

Hydromorphone:
For orally administered IR preparations, the onset of action is approximately ____ minutes with a duration of action of _____ hours

A

30 min

4 hours.

53
Q

Fentanyl:

  • available forms?
  • approximately ____x more potent than morphine and is highly lipophilic and binds strongly to plasma proteins
A
  • IV, intrathecal, epidural, transdermal and oral transmucosal use.
  • **80x more potent
54
Q

which formulation of fentanyl offers a convenient delivery system for patients with chronic pain, particularly those with difficulty swallowing or malabsorption?

A

transdermal

55
Q

Exposing a fentanyl patch to heat or possibly high fever could increase _____

A

**the release of the drug

56
Q

Concomitant use of drugs that inhibit CYP3A4, especially strong inhibitors such as ______ or ______, can cause dangerous increases in serum concentrations of fentanyl

A

ketoconazole (Nizoral)

clarithromycin (Biaxin),

57
Q

(Actiq), a fentanyl lozenge on a stick, is approved for treatment of ________

A

breakthrough pain in cancer patients already taking strong opioids for persistent pain. Its absolute bioavailability is about 50%, divided equally between rapid absorption from the buccal mucosa and slower GI absorption.

58
Q

Fentanyl is also available in: (list other forms)

A

buccal soluble film (Onsolis), a sublingual tablet (Abstral), a nasal spray (Lazanda) and a sublingual spray (Subsys) for management of breakthrough pain.

59
Q

Opioids: Meperidine

  • brand name?
  • oral absorption?
  • only has ___% of the effectiveness of morphine with significant **anticholinergic & local anesthetic properties
A
  • Demerol
  • NOT well absorbed orally
  • 10%
60
Q

Meperidine should be used only for _______

A

short-term (24-48 hours) treatment of moderate to severe acute pain

61
Q

Repeated doses of Meperidine can lead to the accumulation of _________

A
  • *normeperidine, a toxic metabolite . Normeperidine can cause dysphoria, irritability, tremors, myoclonus and, occasionally, seizures, particularly with impaired renal function, use in the elderly or patient-controlled analgesia
  • Adverse effects of normeperidine are NOT reversible by naloxone
62
Q

In patients taking a ______, meperidine can cause severe encephalopathy and death

A

monoamine oxidase inhibitor

63
Q

Codeine:

Its analgesic potency is approximately ___% of morphine with half-life of 2.5 to 3 hours

64
Q

What are some inhibitors of Codeine?

A

bupropion, celecoxib, cimetidine, and cocaine

65
Q

Doses of codeine greater than ____ mg are not well tolerated.

66
Q

Hydrocodone is a combination product with _______

A

non-opioid analgesics, such as ibuprofen and acetaminophen

67
Q

Hydrocodone bioavailability after oral administration is high, and the half-life of hydrocodone is ____ hours

A

2.5-4 hours

68
Q

Tramadol is an oral, centrally-acting opioid agonist that blocks _______

A

reuptake of norepinephrine and serotonin, is marketed for treatment of moderate to moderately severe pain

69
Q

What ADR has been reported with tramadol?

What is the max dose of tramadol per day?

A

**seizures

Dosages of tramadol should not exceed **400 mg per day

70
Q

Opioid ADR: constipation
tx?

Opioid ADR:
sedation tx?

A
  • bowel regimen

- Tolerance typically develops. Hold sedatives/anxiolytics, dose reduction; Consider CNS stimulants

71
Q

Opioid ADR:
-N/V tx?

-Pruritus tx?

A
  • Dose reduction, opioid rotation, consider metoclopramide, prochlorperazine, scopolamine patch
  • Dose reduction, opioid rotation, consider antihistamine or H2 blocker
72
Q

Opioid ADR:

  • Hallucinations tx?
  • Confusion/delirium tx?
A
  • Dose reduction, opioid rotation, consider neuroleptic therapy (haloperidol, risperidone)
  • Dose: reduction, opioid rotation, neuroleptic therapy (haloperidol, risperidone)
73
Q

Opioid ADR:

-myoclonic jerking tx?

A

Dose reduction, opioid rotation, consider clonazepam, baclofen

74
Q

Opioid ADR:

-Respiratory depression tx?

A

Sedation precedes respiratory depression. Hold opioid. Give naloxone

75
Q

Antidote for narcotics?

A

naloxone (narcan)**

76
Q

If you have a DEA, it’s the law to use a _______ when it comes to narcotic prescribing

77
Q

What meds are the mainstay of treatment for a variety of neuropathic pain syndromes?

A
  • antidepressants

- anticonvulsants

78
Q

List ex’s of indications when antidepressants and anticonvulsants can be prescribed (Most not approved by FDA for these indications)

A
  • Postherpetic neuralgia
  • Diabetic neuropathy
  • Fibromyalgia
  • Complex regional pain syndrome and phantom limb pain

Note: Combination use of antidepressant and anticonvulsant medication may produce synergistic increases in analgesic effect in neuropathic pain syndromes.

79
Q

List ex’s of TCAs that can be used for neuropathic pain

A

-TCA (amitriptyline (Elavil), nortriptyline (Pamelor) and imipramine (Tofranil)) can relieve many types of neuropathic pain, including:
diabetic neuropathy, postherpetic neuralgia, polyneuropathy, fibromyalgia, nerve injury or infiltration with cancer

*SSRIs appear to be less effective than TCAs for treatment of neuropathic pain

80
Q

List ex’s of SNRIs that can be used for neuropathic pain

A

-Venlafaxine (Effexor) has been reported to be effective in neuropathic pain and has also been used to treat HA, fibromyalgia and postmastectomy pain syndrome

  • Duloxetine (Cymbalta) is approved for treatment of pain associated with diabetic peripheral neuropathy and fibromyalgia
  • -**It is also FDA- approved for treatment of chronic MSK pain; in studies in patients with chronic low back pain or osteoarthritis, duloxetine was modestly more effective than placebo
  • Duloxetine appears to provide many of the analgesic benefits of older antidepressants with fewer adverse effects.
  • Milnacipran (Savella) is approved by the FDA for use in fibromyalgia
  • ->It appears to be moderately effective in decreasing pain and improving function; how it compares to venlafaxine or duloxetine remains to be est
81
Q

What should you be concerned about when prescribing Venlafaxine (effexor) for pain management?

A

**Withdrawal symptoms may be troublesome

82
Q

Gabapentin (Neurontin) has been effective in treating: _____ and _______.

-S/E of Gabapentin?

A

**postherpetic neuralgia and diabetic neuropathy

SE: Dizziness, somnolence, edema and weight gain can occur.

83
Q

Pregabalin (lyrica) is similar in structure to gabapentin, and is approved for tx of neuropathic pain assoc. w/ ____, _____, and ______

A

postherpetic neuralgia, diabetic peripheral neuropathy, and fibromyalgia.

84
Q

Is pregabalin a controlled substance?

-S/E of Pregabalin?

A
  • Because of some reports of euphoria, it is a Schedule V controlled substance.
  • The dose can be titrated more rapidly than with gabapentin, and pregabalin can be given twice rather than 3 times daily

SE: Dizziness, somnolence and peripheral edema; significant weight gain

85
Q

Anticonvulsants:

-Carbamazepine is FDA-approved for tx of ______

A

pain due to trigeminal neuralgia

86
Q

Anticonvulsants:

Oxcarbazepine which is related to carbamazepine, has been shown to provide ________

A

similar analgesia with fewer adverse effects

87
Q

Lamotrigine (Lamictal) was effective for treatment of _________

A

central post-stroke pain and HIV-associated painful sensory neuropathies in small trials, but larger trials have been less positive.

88
Q

Lamotrigine (Lamictal) can cause what adverse effect that providers must be aware of?

A

**rash that has sometimes progressed to Stevens-Johnson syndrome.

89
Q

Sodium valproate (Depakote, and others) and topiramate (Topamax) have been used for tx of ________

A

migraine prophylaxis.

90
Q

Adjuvant Pain Meds:
-caffeine: dose? analgesic effect?

-Hydroxyzine: dose? analgesic effect?

A

*Caffeine: Doses of 65-200 mg may enhance the analgesic effect of acetaminophen, aspirin or ibuprofen.

Hydroxyzine–>Doses of 25-50 mg given parenterally may add to the analgesic effect of opioids in postoperative and cancer pain while reducing the incidence of N/V

91
Q

Adjuvant Pain Meds:

-corticosteroids can produce analgesia in some Pts with _______

A

**inflammatory diseases or tumor infiltration of nerves.

92
Q

Adjuvant Pain Meds:

  • Clonidine (catapres): formulations? analgesia?
  • medical marijuana?
A
  • The oral and transdermal patch formulation of the **alpha2- adrenergic agonist may improve pain and hyperalgesia.
  • Medical marijuana has been shown to be effective in multiple sclerosis Pts with central neuropathic pain
93
Q

Adjuvant Pain Meds:topical analgesics are generally safe & well-tolerated
-5% lidocaine patch: used for tx of?

-Topical EMLA: describe

A
  • 5% lidocaine patch (Lidoderm) was approved by the FDA for tx of postherpetic neuralgia
  • Topical EMLA= mixture of local anesthetics lidocaine and prilocaine–>useful for cutaneous anesthesia
94
Q

Adjuvant Pain Meds:topical analgesics

-Synera: describe?

Diclofenac patch (flector): used to tx ?

A
  • Synera=lidocaine and tetracaine in patch, is approved for anesthesia before acute topical procedures such as venipuncture.
  • Diclofenac patch (Flector) has been approved by the FDA for local tx of MSK pain
95
Q

Adjuvant Pain Meds:topical analgesics
-8% Capsaicin patch (Outenza): approved for tx of?

-Diclofenac topical gel (Voltaren 1% gel): approved for tx of _______

A
  • postherpetic neuralgia

- **osteoarthritis in knees and hands.

96
Q

Muscle Relaxants:

Cyclobenzaprine (Flexeril)- causes the most ______ (list S/E)

A

somnolence, dizziness, cognitive slowing. **Caution with tramadol (increased risk of seizures)

97
Q

Muscle Relaxants:

Metaxalone (Skelaxin): S/E ?

A

less drowsiness and cognitive effect

98
Q

Muscle Relaxants:

Carisoprodol (soma): S/E?

A

ataxia, agitation, insomnia, tachycardia. Subject to withdrawl Sx and strong abuse potential, particularly when combined with an opioid

99
Q

Muscle Relaxants:

-Diazepam (valium): helps treat? what level is this controlled substance (schedule) ?

A
  • Reflex spasms due to muscle or joint trauma/ inflammation

- Abuse potential- Schedule IV controlled substance

100
Q

Muscle Relaxants:
Methocarbamol (Robaxin)

-S/E?

A

Less drowsiness and cognitive effects

101
Q

Which muscle relaxants are considered safe during pregnancy and lactation?

102
Q

Cyclobenzaprine and tramadol together can increase risk of ______

A

**seizures

-The efficacy of muscle relaxants is controversial

103
Q

Describe the MOA of acute (abortive) migraine therapy

A
  • Stop or prevent the progression of a headache or reverse a headache that has started
  • Treats pain and other Sx after the attack has begun
104
Q

Describe the MOA of Prophylactic migraine therapy

A
  • Used for Pts with Frequent headaches that cause disability(2 per month)
  • Overuse of acute medication (> 2 times per week)
  • Acute meds are not effective, well tolerated or are contraindicated
  • Reduce the frequency and severity of the migraine attack
105
Q

First-Line Abortive Pharmacological Treatments for Migraines (list)

A
  • NSAIDS
  • APAP
  • ASA/ APAP/ Caffeine(Excedrin)
106
Q

2nd Line Abortive Pharmacological Treatments for migraines (list)

A
  • Triptans
  • ASA or APAP/Caffeine/Butalbital (Fioricet/Fiorinal)
  • Ergotamines
  • Injectable ketorolac (Torodol)
107
Q

Triptans:

-MOA ?

A

MOA: serotonin receptor agonist of the 5-HT1b and 5-HT1D with normalization of dilated intracranial arteries thru:

–>Enhanced vasoconstriction

–>Peripheral neuronal inhibition

–>Inhibition of transmission thru 2nd

–>order neurons of the trigeminocervical complex

108
Q

List Triptans(from quickest to longest) and their formulations

A
  1. Sumatriptan (Imitrex®):
    Subcutaneous
    Nasal spray
    Tablets
  2. Zolmitriptan (Zomig®)
    Tablets
    ODT (ZDT)
    Nasal Spray
  3. Rizatriptan (Maxalt®)
    tabs
    ODT (MLT)
  4. Eletriptan (Relpax®)
    Tablets
  5. Naratriptan (Amerge)
    Tablets
  6. Almotriptan (AxertTM)
    Tablets
  7. Frovatriptan (Frova®)
    Tablets
109
Q

Calcitonin gene-related peptide (CGRP) antagonists function as a ______

A

vasodilator focused on the trigeminovascular system

110
Q

Calcitonin gene-related peptide (CGRP) antagonists:

-list the names of meds that can be given once monthly SQ injection (w/ a longer onset)

A

Aimovig
Ajovy
Emgality
Vyepti

111
Q

Calcitonin gene-related peptide (CGRP) antagonists

-Geptants (=small molecules, rapid brain penetration but metabolized in the liver): list ex’s of oral formulations

A

-Nurtec ODT- prevention and treatment

  • Ubrelvy–> treatment only
  • *Caution with CYP3A4-ketoconazole, clarithromycin, itraconazole
112
Q

Pain management strategies:

  • alternate acetaminophen and an _______
  • combine therapies that are _______
A
  • NSAID

- dissimilar

113
Q

Pain management strategies:

  • use non-pharm and _______ therapies to complement each other
  • Pain contracts/Have only _____ providers manage pain meds
  • Goal of pain management is ______
A
  • pharmacologic
  • one provider**
  • function

Pharmacotherapeutics - Fall 21 (7 decks)

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