Pain Flashcards
ceiling dose for acetaminophen
4,000 mg/day if using for LESS than 7 days
• 3,000 mg optimal for long term use and may become our standard of care
• (Utilize ceiling of 2,000 mg in elderly, or those with organ (liver) dysfunction, or excessive alcohol use, cirrhosis)
ceiling dose for aspirin
4g/day
ceiling dose for ibuprofen
3200mg/day
ceiling dose for ketorolac
150 mg first day, 120mg/day thereafter – DO NOT USE longer than 5 days
NSAIDs contras
CABG, CHF, recent MI, renal dysfunction, aspirin allergy/ hypersensitivity
most common NSAID AE category
GI: Dyspepsia, gastritis, ulcers, bleeding. Protective mucus production is disrupted, increase in gastric acid production.
BBW for NSAIDs
increased risk of MI and stroke in all pts
NSAID interactions
ACE-I (risk of renal impairment), FQ (lowers seizure threshold), corticosteroids (risk of ulcers), anti-hypertensives (increases BP slightly), aspirin (can reduce antiplatelet effect), other NSAIDs (never combine)
GI AE from NSAIDs can be serious/fatal in whom?
GI can be serious/fatal in elderly, hx of PUD or GI bleeding, H pylori infx, heavy alcohol use, steroid use
pt counseling for NSAIDs
Onset will be in 20-30 min; take w/ food and full glass of water so it doesn’t irritate your stomach or cause an ulcer
NSAIDs need routine monitoring for what things
renal failure, hepatic dysfunction, and GI ulceration (gastric > duodenal)
age contra for ibuprofen
<6 mo
age contra for naproxen
<12 y/o
ibuprofen analgesic, etc dosing
Analgesic Dose = 1200 - 1800mg / day
Anti-Inflammatory Dose = 1800-2400mg/d
Anti-Rheumatic Dose = 2400-3200mg/day
ceiling max of ibuprofen is ok for how many days
3-5
ceiling dose for naproxen
ceiling = 500mg Q12 hr
go-to IV or IM NSAID
ketorolac
contras for Indomethacin (Indocin)
Caution: elderly, epilepsy, psych disorders, Parkinsons
pt counseling for voltaren gel
Voltaren: wash hands well after application; do not cover w/ dressings or apply heat; do not use w/ other topical lotions/meds; don’t wash off/shower for 1 hr
longest half life NSAID
Piroxicam (Feldene)
contras for Celecoxib (Celebrex)
post-CABG, aspirin or sulfa allergy
BBW for Celecoxib (Celebrex)
MI
indications: mild-mod pain and inflammation at high doses only, prevention of MI/stroke, ACS, Dressler’s syndrome, fever, prophylactic for colon cancer
aspirin
contra for aspirin
kids (Reye’s syndrome)
aspirin toxicity signs
Toxicity: n/v, diaphoresis, tinnitus, hyperventilation
treatment for aspirin toxcitiy
dialysis
interactions: Anticoagulants, Lithium, Certain Antihypertensives
aspirin
early symptoms of tylenol overdose
N/V/D, abdominal pain
treatmetn for tylenol overdose
Acetylcysteine (Acetadote®, NAC, Mucomyst) or activated charcoal (if w/in 4 hrs)
tylenol and NSAID combo that beats opioids
1g acet + 400mg ibuprofen > opioids
AEs: “CNS depression (drowsiness/confusion)
Headache
Hypotonia (weakness/low muscle tone)”
baclofen
baclofen withdrawal symptoms
PO: Seizures, hallucinations, etc.
Intrathecal: severe sequelae (hyperpyrexia, obtundation, rebound/exaggerated spasticity, muscle rigidity, and rhabdomyolysis), leading to organ failure and some fatalities
Slow taper over 2 weeks is needed
interactions for diazepam (Valium)
Metabolised by CYP34A to active. Avoid opioids: respiratory depression. Avoid alcohol: Increased effect of alcohol. Excess grapefruit will increase effect of diazepam
contra / interaction for •tizanidine (Zanaflex)
cipro
AEs: “Drowsiness. Hypotension )Especially when combined with other antihypertensives)
Dizziness. Dry mouth. Hepatotoxicity: Monitor LFTs regularly with long-term use”
•tizanidine (Zanaflex)
withdrawal symptoms of •tizanidine (Zanaflex)
Abrupt withdrawal may result in rebound hypertension, tachycardia, and hypertonia (if pt was receiving high doses for prolonged periods ≥9 weeks)
indications for dantrolene
*dantrolene (Dantrium) PO for spasticity, IV
Chronic muscle spasms. Primarily to treat malignant hyperthermia- complication of general anesthesia
AEs: respiratory tract infections, muscle weakness, urinary incontinence, falls, fever, pain
botox
which spasmolytic is Structurally related to tricyclic antidepressants (TCAs)
cyclobenzaprine (Flexeril)
is flexeril rec for low back pain
no
cyclobenzaprine (Flexeril) CI
contras
Caution in elderly. Avoid use if history of arrhythmias, CHF, hyperthyroidism, glaucoma or MAOI use in the past 14 days
SE of all antispasmodics
CNS depression / sedation
cyclobenzaprine (Flexeril) interactions
interactions
serotoninergic drugs, alcohol, opioids
Pt cousenling for flexeril
Counsel against operating heavy machinery or driving.
how long to describe flexeril / antispasmodics
max 3 wks
contras: metaxalone (Skelaxin)
“Caution in elderly.
Absolute: severe renal or hepatic dysfunction “
AEs: "Sedation, esp when combined w/ alcohol or opioids. CNS depression, Hallucinations, Anticholinergic effects (Dry mouth, blurred vision, urinary retention, dizziness, hypotension, constipation, increased intraocular pressure) Serotonin syndrome (Monitor if on other serotoninergic drugs)"
flexeril
AEs: Sedation, esp when combined w/ alcohol or opioids. CNS depression. Bradycardia, hypotension, syncope, flushing. Pruritus, rash, urticaria. Dyspepsia, N/V
methocarbamol (Robaxin) PO, IV, IM
AEs: Sedation, esp when combined w/ alcohol or opioids. Fairly benign adverse effect profile…although fatalities attributed to its use have been reported. Hemolytic anemia. Leukopenia. Impaired liver function. CNS depression
metaxalone (Skelaxin)
contras: carisoprodol (Soma)
Caution in elderly. patients with past substance abuse/addiction
AEs: Sedation, esp when combined w/ alcohol or opioids. CNS depression (Very sedating), Seizures. Physical and psychological dependence (Schedule IV)
carisoprodol (Soma)
AEs: “Sedation, esp when combined w/ alcohol or opioids. CNS depression. Urine discoloration (red or orange). Rash, petechiae, angioedema.
Hepatotoxicity: Rare, serious (including fatal) idiosyncratic and unpredictable hepatocellular reaction (discontinue)”
chlorzoxazone (Lorzone, Parafon Forte)
2 categories that are first line for neuropathic pain
anticonvulsants, SNRI
AEs: Significant dizziness and sedation. Serious and possibly fatal respiratory depression may occur (Risk increased when combined with opioids or other sedatives; Elderly/underlying respiratory disease at higher risk). Euphoria (abuse potential)
Gabapentin (Neurontin), Pregabalin (Lyrica)
couseling for Duloxetine(Cymbalta)
Take on a full stomach to reduce nausea
AEs: nausea, Drowsiness, fatigue, headache also common
Duloxetine(Cymbalta)
AEs: Drowsiness, dizziness, diaphoresis, nausea, anorexia (all actually fairly common)
Venlafaxine(Effexor)
AEs: Anticholinergic effects: dry mouth, urinary retention, constipation, delirium, sedation, orthostatic hypotension
TCAs: “Nortiptyline (Pamelor)
Amitriptlyine (Elavil)”
