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PHAR154 > OTC Analgesics > Flashcards

OTC Analgesics Flashcards

1
Q

What is the equivalent dose to 10mg of morphine for acetaminophen, aspirin, ibuprofen, and naproxen?

A

acetaminophen: 3600mg
aspirin: 3600mg
ibuprofen: 2220mg
naproxen: 1380mg

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2
Q

What do you mean when we say “10mg morphine equivalent dose”?

A

we need this amount of agent to get to the same painkilling level as 10mg of morphine

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3
Q

What is the max dosing of OTC NSAIDs?

A

ibuprofen: 1200mg
naproxen: 440mg

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4
Q

Does morphine plateau in pain relief?

A

no, pain relief increases as dose increases

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5
Q

At what strength does ibuprofen peak in pain relief for an individual dose?

A

400mg
-anything greater is along for the ride + greater risk of se

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6
Q

At what strength does acetaminophen peak in pain relief for an individual dose?

A

1000mg

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7
Q

At what strength does aspirin peak in pain relief for an individual dose?

A

1000mg

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8
Q

At what dose does ibuprofens anti-inflammatory mechanism truly peak?

A

400-800mg TID/QID
-past the max OTC dose
-thus its tough to give OTC dosing ibuprofen any credit for
being anti-inflammatory

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9
Q

Which OTC analgesic is probably the most convenient?

A

naproxen (BID)
-ibuprofen can be up to 6x/day=highly inconvenient

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10
Q

Are Advil Liqui-Gels any better than Advil tablets?

A

no
more expensive
maybe a little bit quicker by 2 minutes
tablets are fine and dissolve quick enough

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11
Q

True or false: at OTC doses, ibuprofen has more side effects than acetaminophen

A

false

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12
Q

What are the nuisance side effects of OTC doses of acetaminophen and ibuprofen?

A

nausea
abdominal pain
dyspepsia

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13
Q

What is something you should never mention during an OTC consult that is revolved around acetaminophen?

A

hepatotoxicity as a side effect

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14
Q

What can taking a pill with food or fluid help with?

A

clearing the pill from the esophagus
help reduce some local damage to stomach

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15
Q

What will taking ibuprofen or acetaminophen with food NOT do?

A

will not prevent GI damage via systemic PG inhibition
food can also delay onset of action

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16
Q

True or false: NSAIDs should be taken with food

A

false
although its totally fine to take with food

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17
Q

What does the balancing the use of medicine depend on?

A

risk vs benefit
-dont be the side effect kings

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18
Q

Which agent is safer at overdose levels, acetaminophen or ibuprofen?

A

ibuprofen

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19
Q

What do products that are advertised as “pain at night” often contain, alongside one of naproxen, acetaminophen, or ibuprofen?

A

diphenhydramine
or methocarbamol (muscle relaxant)

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20
Q

What does insomnia often go hand-in-hand with?

A

pain

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21
Q

What are the most common causes of pain we will see in pharmacy?

A

muscle/back/joint
headache/migraine
cold/flu

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22
Q

What are doctors often looking for in a child before giving a medicine for pain?

A

behavioural signs such as facial expression, crying, irritability, poor feeding, sleep disturbance and inactivity

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23
Q

What is used to treat pain in children?

A

acetaminophen
ibuprofen

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24
Q

What are the OTC options for headaches and migraines?

A

NSAID or acetaminophen
(also triptans for migraines)

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25
Q

What are some differences between headaches and migraines?

A

headaches:
-pain around forehead
-mild, dull pressure
-incidental, non-recurring
migraines:
-pain on sides of head
-intense, pulsing or throbbing
-commonly recurring

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26
Q

What used to be the DOC for osteoarthritis?

A

acetaminophen
-Jeff says you can try for 2 weeks, no relief–>NSAID

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27
Q

What is the DOC for dysmenorrhea?

A

NSAIDs

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28
Q

What is dysmenorrhea?

A

menstrual cramps
caused by contractions in the uterus due to PGs
can start 1-2 days before period and last 2-4 days

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29
Q

What is the most commonly reported menstrual disorder?

A

dysmenorrhea

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30
Q

True or false: caffeine is not needed for dysmenorrhea

A

true

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31
Q

What is the issue with the Advil Plus Acetaminophen product?

A

the doses are not therapeutic

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32
Q

At what dose does caffeine have some value for headaches? What about migraines?

A

130mg
>100mg
-enhances efficacy of analgesics in headaches and migraines

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33
Q

What is medication overuse headaches?

A

the overuse of acute pain-relief medicine ends up causing headaches

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34
Q

Which analgesic combo is more likely to induce MOH?

A

those containing caffeine

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35
Q

How many days per month can caffeine-containing analgesics be used? Why?

A

no more than 9 days per month (JT says 15 days)
due to the potential of MOH
reserve them for 2nd line for TTH

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36
Q

True or false: the MOH type phenomenon is also seen when taking pain relievers for arthritis or back pain

A

false

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37
Q

Which country is the #1 biggest user of codeine?

A

Canada

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38
Q

True or false: codeine products with ASA are still used

A

false
codeine-ASA products no longer exist

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39
Q

What is codeine a prodrug for?

A

morphine

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40
Q

Which enzyme metabolizes codeine to morphine?

A

2D6

41
Q

What is the issue with codeine as an analgesic?

A

depending on genetics, people metabolize codeine to different extents
thus, each person varies with how much morphine they make

42
Q

What is needed before you can sell an exempted codeine product?

A

special training

43
Q

If someone calls you and says “my kid got into ….” which drugs do you not want to hear them say?

A

ASA
acetaminophen

44
Q

True or false: acetaminophen toxicity is a medical emergency

A

true

45
Q

What is the amount of acetaminophen that causes hepatic toxicity in adults/adolescents?

A

7.5-10g in <8hr
24 regular/15 extra strength

46
Q

At what dose of acetaminophen are fatalities rare in adults/adolescents?

A

<15g
45 regular/30 extra strength

47
Q

What is the therapeutic dose of acetaminophen in pediatrics?

A

10-15mg/kg/d
max 75mg/kg/d

48
Q

At what dose of acetaminophen are there overdose concerns in pediatrics?

A

150-200mg/kg

49
Q

What is the max daily dosing of acetaminophen in the USA?

A

3000mg
-they are concerned about people not knowing
acetaminophen is present in other products

50
Q

What is the max dosing of acetaminophen per day in adults?

A

4g

51
Q

What do the vast majority of people who overdose on ibuprofen experience?

A

no symptoms to mild symptoms
safe drug in overdose
still get to the hospital

52
Q

True or false: ibuprofen is commonly fatal from overdose

A

false

53
Q

What do NSAIDs do to a drug like warfarin which is bound to plasma proteins?

A

NSAIDs bounce the drug off the protein
=more free drug

54
Q

True or false: acetaminophen does not bounce drugs off of plasma proteins

A

true

55
Q

Has the safety profile of acetaminophen changed while taking warfarin?

A

yes, the mechanism of interaction is unknown
more frequent monitoring is suggested

56
Q

What are the doses of acetaminophen we need to worry about for someone taking warfarin?

A

> 2.25g per week starting point for concern
2.5g per week could be impactful

57
Q

Which drugs should be avoided while on a DOAC?

A

NSAIDs
-increases risk of GI bleed which can be exacerbated by
DOAC

58
Q

What is the mechanism of a child getting asthma via acetaminophen?

A

acetaminophen reduces the bodys level of a natural free scavenger (glutathione)
exposure during pregnancy or early infancy

59
Q

True or false: acetaminophen during pregnancy has been associated with development of ADHD and asthma in offspring

A

true

60
Q

If you have asthma, but arent ____, you should be able to take ibuprofen. If you have ____, ibuprofen can trigger symptoms of asthma.

A

aspirin-sensitive
aspirin-sensitive asthma

61
Q

What are the chances of the general population having an aspirin allergy? What about people with allergies, asthma, and urticaria?

A

1-2%
10-30%

62
Q

If someone has an ASA allergy, what are the odds of them having an ibuprofen or naproxen allergy?

A

ibuprofen: cross-sensitivity with ASA is 98%
naproxen: cross-sensitivity with ASA is 100%

63
Q

If someone has an ASA allergy, which agents should also not be used?

A

ibuprofen and naproxen=higher risk of asthma exacerbations
-if the person is not ASA-sensitive, these agents can be used

64
Q

When is ASA-induced asthma usually seen?

A

adulthood

65
Q

If an elderly person comes in and asks “where is your Advil?”, what should be one of the first things that comes to mind?

A

are they on ASA???

66
Q

What does the balance look like for ASA use?

A

preventing a heart attack vs risk of GI bleed

67
Q

What is going on in the body when only ASA is in the blood?

A

cardio-proection
-ASA binds to COX-1 on platelets
-platelets are less sticky

68
Q

What is going on in the body when ASA and ibuprofen are both present in the blood?

A

ibuprofen can hit the COX-1 receptor before ASA
-benefit of ASA is now neutralized
-no cardio-protection
increased risk of GI issues with regular use of any NSAID+ASA

69
Q

If you want to avoid the ASA-ibuprofen interaction, what would this look like?

A

take ibuprofen 2 hours after ASA
OR
take ibuprofen 8 hours before ASA
MULTIPLE DAILY DOSES WILL BE A PROBLEM

70
Q

Does naproxen interact with ASA to the same degree as ibuprofen?

A

less likely to interact, but still some evidence
avoid if regular use is planned

71
Q

Can ASA be taken with ASA?

A

low potential option but GI risk increases
cant interact with itself on the platelet
-getting CV protection and relief from x

72
Q

Does Voltaren have an interaction with ASA?

A

no
-topical
-first choice for people on ASA

73
Q

True or false: Voltaren is to be used for headaches and not for joint pain

A

false
not headaches, used for joint pain

74
Q

True or false: many analgesics have been shown to be absolutely contraindicated during pregnancy

A

false

75
Q

What category does acetaminophen fall under in pregnancy?

A

category B
-commonly used in all stages
-appears to be no risk at standard doses

76
Q

Flow to the lungs is not needed in a fetal heart, what is the structure on the fetal heart that allows the mother to pass oxygen to the fetus? What happens to this structure when the fetus is born?

A

patent ductus arteriosus
closes at birth, blood now shunts to baby’s lungs

77
Q

What maintains the opening of the ductus arteriorus until birth?

A

prostaglandins

78
Q

What category does ibuprofen fall under in pregnancy?

A

category C up to 30 weeks
-reasonably safe up to week 30
category D >30 weeks
-premature closing of ductus arteriosus and increased risk of
bleeding

79
Q

Which category does naproxen fall under in pregnancy?

A

category C
avoid late in pregnancy because of PDA closure=category D
risk in 1st trimester too (spontaneous abortion)

80
Q

Which category does ASA fall under in pregnancy?

A

category C
category D in 3rd trimester

81
Q

What are the normal impacts of COX-1 on the body?

A

helps protect GI
negative impact on cardiovascular system

82
Q

What are the normal impacts of COX-2 on the body?

A

causes inflammation
positive cardiovascular impact

83
Q

Which agents are commonly found in combination products of NSAIDs for long term usage?

A

PPIs
-help GI protection that is lost by using NSAID

84
Q

True or false: ibuprofen and naproxen will block both COX-1 and COX-2 to varying degrees

A

true
blocking the negative impact on CV (COX-1) and inflammation (COX-2)
also blocking the positive impacts on GI (COX-1) and CV (COX-2)

85
Q

In general, we say ibuprofen is safer for ____ and naproxen is safer for ___.

A

ibu safer for GI
naproxen safer for CV

86
Q

What are the drug interactions associated with NSAIDs?

A

drugs that negatively affect GI (steroids): increase GI risk
anticoagulants: increase bleeding risk
blood pressure meds: increase CV risk
SSRIs: increase GI risk
ASA 81mg: increase GI risk
alcohol: increase GI risk

87
Q

True or false: acetaminophen should absolutely be avoid for a hangover

A

false

88
Q

Explain the interaction between alcohol and acetaminophen.

A

acet normally conjugated to nontoxic conjugated metabolites or can be metabolized to a toxic metabolite NAPQ by P450, but this is normally fixed by glutathione
chronic alcohol induces P450 and depletes glutathione, thus we get a buildup of NAPQ

89
Q

What is the reality of using acetaminophen for someone with cirrhosis like an alcoholic?

A

patients with cirrhosis have lower clearance of acet
use <2g per day, including those who continue to drink

90
Q

What is the verdict on acute alcohol ingestion and acetaminophen?

A

not a risk factor for hepatotoxicity
may even be protective by competing for CYP2E1

91
Q

What are the issues with NSAIDs and the eldery?

A

decreased renal
more medicines
more conditions
more bleed risk
more CV issues
=big concern for the elderly to be taking an NSAID

92
Q

When might NSAIDs be an issue with sports?

A

dehydration
-PGs help kidney perfusion, NSAIDs block this

93
Q

True or false: NSAIDs have reliable effects on acute injury swelling

A

false
could affect the healing and re-modelling

94
Q

What is the only reliable way to treat MOH?

A

stop the headache medicine

95
Q

What is the usual dosage of codeine for adults?

A

15-60mg q4h prn
max 360mg q24h

96
Q

Do enteric coatings of NSAIDs prevent stomach bleeding?

A

no, just as likely to cause stomach bleed (rare in the first place)
its the systemic effect that causes stomach bleeding

97
Q

How should NSAIDs be taken for acute pain when a rapid onset of effect is desired?

A

empty stomach with a full glass of water
FOOD DELAYS AND MAY REDUCE ANALGESIC EFFECT

98
Q

True or false: there is a risk of GI bleed when alcohol is taken with an NSAID

A

true

99
Q

What are the rates of nausea, abdominal pain, and heartburn for ibuprofen? What about acetaminophen?

A

ibuprofen:
-nausea: 6.3%
-abdominal pain: 2.7%
-dyspepsia: 5.4%
acetaminophen:
-nausea: 4.5%
-abdominal pain: 5.4%
-dyspepsia: 0.9%

PHAR154 (18 decks)

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