OTC Analgesia Flashcards
1
Q
What doses of acetaminophen, ibuprofen, and naproxen are equivalent to 10mg oral morphine?
A
acetaminophen: 3600mg
ibuprofen: 2220mg
naproxen: 1380mg
2
Q
which OTC analgesic can we get to 10mg oral morphine equivalents in within daily max dosing?
A
acetaminophen
3
Q
what enzyme converts codeine to morphine?
A
2D6
4
Q
why is codeine efficacy inconsistent?
A
prodrug of morphine
fast vs. slow metabolisers of 2D6
5
Q
what is the analgesic ceiling for morphine, ibuprofen, acetaminophen and ASA? (in a single dose)
A
morphine: no ceiling
ibuprofen: 400mg
acet/ASA: 1000mg
6
Q
T of F
we have to dose above the analgesic ceiling of NSAIDs in order to have any anti-inflammatory actions?
A
true
7
Q
T or F
at OTC doses, ibuprofen has more side effects than acet?
A
false
equivalent in “nuisance side effects”
8
Q
what percentage of people will have nuisance side effects from ibu/acet at OTC doses?
A
around 10%
9
Q
what are considered nuisance side effects of OTC analgesics?
A
nausea, abdominal pain, dyspepsia
10
Q
does taking NSAIDs with food help reduce the risk of ulcers?
A
it can help to decrease some local damage
it will NOT prevent GI damage via systemic PG inhibition therefore long term it does nothing
11
Q
taking ibuprofen on an empty stomach will increase the onset of action by how much?
A
5-10 mins
12
Q
how much sooner is the onset of effect in gel caps analgesics?
A
2-5 mins
13
Q
why are some analgesics coated?
A
usually just to make taste better
14
Q
what percentage of pain patients experience insomnia?
A
60-80%
15
Q
why does pain get worse at night?
A
staying still in one position might cause joints to stiffen up
16
Q
which analgesic is best for fever?
A
up to preference
17
Q
what are the DOC in headaches/migraines?
A
NSAIDs or acet or triptans
18
Q
what is special about Advil 12 hours?
A
has 300mg on the outside and 300mg on the inside - lasts 12 hours
19
Q
when can topical diclo be used in OA?
A
small number of isolated joints
20
Q
what is the DOC in dysmenorrhea?
A
NSAIDs
21
Q
what causes menstrual cramps?
A
contractions (tightening) in the uterus by a prostaglandin
22
Q
what is usually in midol?
A
acetaminophen
caffeine
pyrilamine maleate (antihistamine)
23
Q
what is the purpose of caffeine in midol?
A
diuretic
dose not high enough to be analgesic
24
Q
is the caffeine in midol effective as a diuretc?
A
if caffeine naive yes
if not caffeine naive then no
25
what does "2-4-24" refer to?
2 drugs (acet and ibu)
4 doses in 24 hours
26
what is the problem with combogesic?
only contains 97.5mg of ibuprofen so at 2 tabs wont have a lot of effect
27
why would we pick naproxen over ibu?
more CV safe (but worse for GI)
more convenient - only BID
28
what amount of caffeine is needed to have a synergistic effect with analgesics?
over 100mg
29
what doses of caffeine is needed to enhance efficacy of analgesics in tension headaches and migraines?
>130mg in TTH
>100 in migraines
30
T or F
analgesics formulated with caffeine are less likely to cause MOH
false
they are MORE likely to cause MOH
31
which OTC analgesics are we most worried about in an OD situation?
ASA and acetaminophen
32
at what dose does hepatic toxicity concern with acetaminophen in adults/adolescents?
7.5-10g in <8h
double the daily max within 8 hours
24 regular strength or 15 extra strength tabs
33
at what dose are acetaminophen levels drawn in pediatric OD?
150-200mg/kg
34
what is the therapeutic dosing of acetaminophen in children?
10-15mg/kg q4-6h
max: 75mg/kg
35
T or F
ibuprofen ODs are typically mild with little to no side effects
true
36
how does ibuprofen interact with warfarin?
bounces warfarin off of plasma proteins = more free warfarin
37
what is the interaction between acetaminophen and warfarin and at what dose does this become a concern?
unrelated to albumin
increases INR in dose-dependent matter
doses >2.25g per week = concern
doses >2.5g per week = impactful
38
what is the interaction between NSAIDs are DOACs?
no albumin interaction
but increases bleeding risk
39
can asthma worsen asthma?
no
40
what is the proposed mechanism of acetaminophen during pregnancy causing asthma?
it reduces the bodys natural level of glutathione (free radical scavenger)
41
does acetaminophen use in pregnancy cause ADHD?
no
42
when does ASA sensitive asthma usually develop?
in adulthood
43
what are the rates of ASA-allergy in the general population vs what is it in people with allergies/asthma?
gen pop = 1-2%
asthma/allergies = 10-30%
rates increase 10 fold
44
what is the cross sensitivity of an ASA-allergy with ibu and naproxen and what do these numbers mean?
ibu = 98%
naproxen = 100%
means that people are reacting to the NSAID not the salicylate
45
can someone with an ASA allergy take celecoxib?
yes
COX1 inhibition seems to be the issue
46
celecoxib is selective for which enzyme?
COX2
47
What is the DOC for people taking ASA 81?
acetaminophen
48
if someone who is taking ASA 81 wants to take ibuprofen, how long would they have to separate them by?
2 hours after ASA
or 8 hours before ASA
49
how is ASA cardioprotective?
blocks COX1 receptors on platelets making platelets "less sticky"
50
do migraines get better or worse in pregnancy?
1/3 get better
1/3 get worse
1/3 stay the same
51
what FDA category is acetaminophen in pregnancy?
B
52
what is the physiology of the ductus arteriosus in the fetus?
before you are born it allows blood to bypass babies lungs
after you are born it closes... blood now shunts to babys lungs
53
what maintains the patency of the ductus arteriosus until birth?
prostaglandins
54
what FDA category is ibuprofen in pregnancy?
C < 30 weeks
D > 30 weeks
55
what is the concern with NSAIDs in pregnancy >30 weeks?
premature closure of the ductus arteriosus and increase bleeding at term
can also result in low amniotic fluid >20 weeks
56
what is the background rate of birth defects?
3-5%
57
COX1 = ______ protective
COX2 = ______protective
GI
Cardio
58
inhibition of which COX enzyme has negative CV impact?
COX2
59
inhibition of which COX enzyme has negative GI impacts?
COX1
60
T or F
H2RAs are recommended for patients on long term NSAID therapy
false
PPIs better
61
if someone takes NSAIDs once a month, is it recommended to take it with a PPI?
no
PPIs take a couple of days to work so will have no impact
H2RAs might work
62
T or F
stopping NSAID therapy is more significant for lowering CV risk in CVD than smoking cessation or weight loss
false
63
T or F
naproxen is cardiac neutral
some reports say yes but still use with caution
64
if someone had an MI, what are the chances of having another one within 5 years?
20%
65
T or F
you can safety use NSAIDs in patients on glucocorticoid therapy
false
66
what is the interaction between BP medications and NSAIDs?
no interaction with the actual medication but may increase BP
as well, thromboxane increases CV risk
67
how much does bleeding risk increase with SSRI therapy?
7 fold
68
what toxic metabolite does acetaminophen create?
N-acetyl-p-benzoquinone imine (NAPQI)
69
what enzyme converts acetaminophen to NAPQI?
CYP 2E1
70
what is the bodys "bale out" system for dealing with NAPQI?
glutathione (SH donor) turns NAPQI into a nontoxic conjugated metabolite
71
why is NAPQI bad?
causes damage by binding to SH in cellular structures
cytotoxic to the liver
72
T or F
all acetaminophen is metabolised by CYP 2E1
False
some is conjugated to make a non toxic metabolite
73
Why do children have less risk of acetaminophen induced hepatotoxicity?
they have enhanced sulphation so less acet is metabolised by CYP2E1 into NAPQI
74
what is the issue with taking acetaminophen in chronic alcoholism?
CYP2E1 is upregulated --> increased NAPQI
decreased stores of glutathione so there is no bale out system for NAPQI
75
T or F
acetaminophen should not be used in a hangover in acute alcohol drinkers due to its liver risks?
false
not an issue with occasional drinkers, may even be protective against NAPQI
76
how might acute alcohol ingestion actually protect the liver from acetaminophen?
competes for CYP2E1
therefore less NAPQI made
77
what dose of acetaminophen is safe in patients with cirrhosis?
<2g/day
78
what dose of acetaminophen is dangerous in alcoholics?
>2g/day
79
T or F
ibuprofen can be taken for a hangover
true
may increase GI bleed risk
80
T or F
elderly patients should not take NSAIDs at OTC doses
false
not a lot of concern at OTC doses
81
why would we be worried about NSAIDs in elderly patients?
decreased renal function
more medications
more medical conditions
more bleed risk
more CV risk
BUT MORE PAIN
82
why is taking NSAIDs while dehydrated harmful?
kidneys need PG for perfusion
dehydration decreases perfusion to kidneys
therefore, NSAID + dehydration = even less perfusion than either alone
83
T or F
we want to stop inflammation in a sprained ankle
false
new evidence that inflammation may be helpful
84
why is RICE no longer recommended?
rest and ice may not be a good idea
85
T or F
ibuprofen at OTC doses is anti-inflammatory
false
86
what percent of low back pain sufferers will go on to have chronic back pain?
25%
87
why is movement recommended for injuries?
may help remodelling
88
what is nociplastic pain?
pain that has no evidence of damage or inflammation
psychosomatic
89
T or F
most back pain is caused by injury
false
complex interaction on pain perception, emotions, attitudes, stress, physical activity, HCP relations, etc etc
90
what is the conclusion of using acet for back pain?
likely no effect
try for 2 weeks then reasses
91
what dose of methocarbamol is in all robox products?
500mg
92
at OTC dosing, which robax product may have anti-inflammatory properties?
robaxisal (ASA)
93
T or F
topical lidocaine works for back pain
false
doesnt penetrate deep enough
94
at what does is ibuprofen anti-inflammatory
RX doses
400-600mg TID
95
what is the active ingredient in deep cold and what does it do?
methylsalycylate
counter irritant
96
what is the active ingredient in icy hot and what does it do?
menthol
counter irritant
hits cool receptors for 30 mins then feels warm
97
T or F
using a heating pad with counterirritants will help
false
will cause burns
98
what is the DOC for pain in patients >75?
topical diclofenac
99
what percent of topical diclofenac is in regular strength and extra strength voltaren and what are their dosing intervals?
regular: 1.16% - TID-QID
extra: 2.32% - BID
100
T or F
all voltaren products have a dosing card included
false
only extra strength does
101
what is special about voltaren joint pain?
just has a fancy applicator
may make use easier for elderly/people with mobility issues
102
if you use 1 FTU of regular strength Voltaren, how much diclofenac are you using?
1 FTU = 2 cm
2cm = 1g gel
1g gel = 11 mg diclo
103
which antidepressants are useful for neuropathic pain?
TCAs and duloxetine
104
which TCA has less side effects?
nortriptyline
105
what is the treatment of shingles in the acute phase?
antivirals within 72 hours of rash formation
analgesics
cool compress/calamine for itch
106
how long after shingles rash formation do you have to receive antivirals?
72 hours
107
what is the treatment of post herpetic neuralgia?
TCAs
gabapentin/pregab/carbamazepine
Capsaicin
108
what is Zostrix?
capsaicin 0.075%
109
how does capsaicin work in post herpetic neuralgia?
decreases substance P in nerve fibers with regular use
110
how often should capsaicin be used for post herpetic neuralgia?
TID
111
T or F
capsaicin can be dosed prn for post herpetic neuralgia
False
needs to be used regularly to decrease substance P in nerve fibers
