NSAIDS And Non Narcotics

Question 1

6 common indications for NSAIDS?

Answer 1

Osteoarthritis
Bursitis
Gout Flare up
AS
Dysmenorrhea
HA

Question 2

4 similarities of COX1 and COX 2?

Answer 2

Use same substrates, AA
Both make the same products, PGs
Both have role in inflammation
Both have role in renal function

Question 3

Where is COX1 and COX2 expressed in the body? Where in the body does COX 2 have a prominent physiological role?

Answer 3

COX 1 in all tissues all the time
COX2 in some tissues and sometimes.
COX2 has a big role in kidney

Question 4

3 step sequence to go from inflammation to symptoms with COX1?

Answer 4

1. Inflammation stimulates AA release
2. COX1 converts AA into PGE2
3. PGE2 causes symptoms

Question 5

Same question, 3 step sequence from inflammation to symptoms for COX2?

Answer 5

1. Inflammation induces COX2 expression and AA release
2. COX2 also converts AA into PGE2
3. COX2 derived PGE2 amplifies symptoms

Question 6

What is the 1 benefit we are looking for when giving a COX1 and 2 inhibitor?
What are risks of giving COX inhibitors?

Answer 6

Block inflammation

COX1 mucosal integrity
COX1 hemostasis
COX1 and 2 sodium and water excretion

Question 7

4 major beneficial actions of inhabiting both Cox 1 and 2 and one beneficial action that is inhibiting only COX 1, all by aspirin?

Answer 7

Suppress inflammation
Relief of mild to moderate pain
Reduce fever

Prevent of MI and stroke by suppresses platelet aggregation

Question 8

3 major risks of inhabiting cox 1 and 2 by aspirin?

Answer 8

Gastric ulcer, bleeding and renal impairment

Question 9

MOA of aspirin?

Answer 9

Irreversible inhibition of cyclooxygenase

Question 10

3 things he mentioned that aspirin is really good at treating?

Answer 10

Pain, RA, and chronic inflammation

Question 11

What 2 things we can go to minimize risk of aspirin induced ulcers?

Answer 11

Test/get rid of H pylori before therapy

Give a proton pump inhibitor

Question 12

3 other clinical conditions we are mindful about giving aspirin?

Answer 12

1. People on anticoagulants because of its anti platelet effects
2. Implied renal function can cause retention of sodium and water, so heart or HTN patients
3. Aspirin induced asthma, causes more LT doing its inflammatory thing

Question 13

What can long term aspirin use lead to in the kidney and what are we worried about with aspirin and children?

Answer 13

Renal papillary necrosis

Reye syndrome in kids with chick pox or the flu

Question 14

2 big differences between aspirin and other NSAIDS?

Answer 14

They reversibly block, so their effects decline as blood levels decline
Increase risk for MI and Stroke

Question 15

Which COX does celecoxib block?
What does it cause less of than other NSAIDS?
What does it not inhibit?

Answer 15

Blocks COX2
Less gastric ulceration
Does not inhibit platelet aggregation, so does not cause bleeding

Question 16

Coxibs, or second generation NSAIDS block which Cox?

Answer 16

2

Question 17

3 general consensus for NSAIDS and patients with cardiovascular risk?

Answer 17

1. All NSAIDS used at lowest dose
2. Goal is to avoid NSAIDS and cox 2 inhibitors all together
3. If need to use NSAID therapy with a patient who has cardiovascular risk, use Naproxen

Question 18

5 contraindications for NSAID use?

Answer 18

1. Chronic kidney disease with creatinine clearance less than 60
2. Ulcers
3. CV disease, particularly HR and HTN
4. NSAID allergy
5. Anticoagulant

Question 19

4 things that acetaminophen doesn’t do that NSAIDS do?

Answer 19

No Anti-inflammatory action
doesn’t cause ulcers
Does not suppress platelet aggregation
Does not impair renal function

Question 20

2 complications of acetaminophen?

Answer 20

Hepatic necrosis when glutathione is depleted

Inhibits metabolism of warfarin, so bleeding

Question 21

Step 1-5 of aspirin toxicity progression?

Answer 21

1. Uncoupled mitochondrial oxidative phos in CNS
2. Respiratory center registers the low ATP as hypoxemia, so hyperventilation is turned on
3. This leads to respiratory alkalosis which tells the kidney to ditch its bicarb
4. Acids accumulate because ATP is not being made
5. Severe metabolic acidosis

Question 22

3 first line agents for neuropathic pain?

Answer 22

Calcium channel alpha 2 delta ligand, gabapentin
SNRI
TCA

Question 23

2 beneficial effects of TCA?

Answer 23

Pain relief and depression relief

Question 24

2 beneficial effects of SNRIS and MOA?

Answer 24

Pain relief and relief of concurrent depression

Inhibit serotonin and norepinephrine

Question 25

MOA for pregabalin?

4 approved indications for pregabilin?

Answer 25

GABA analog that binds to the alpha 2 delta submit of voltage gated calcium channels in the CNS and not allowing as much calcium in, thereby inhibiting NT release.

Neuropathic pain with diabetic neuropathy, postherpatic neuralgia, partial seizures, and fibromyalgia

Question 26

MOA for gabapentin?
Approved use?
Off label uses?

Answer 26

Same as pregablin
Broad spectrum seizure med
Same 4 but also RLS and migraine

Question 27

What are 3 second line agents for neuropathic pain?

Answer 27

Other antiepileptics
Opioids
Tramadol

Question 28

MOA of tramadol?
Clinical indication?
5 adverse effects?

Answer 28

Weak mu analog that primarily blocks NE and 5HT reuptake
Moderate to moderately server pain
Sedation, dizziness, headache, dry mouth, and constipation

Question 29

MOA of tapentadol?

Adverse effect?

Answer 29

Moderate to strong mu agonist and blocks re uptake of NE

Causes less constipation