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Clinical Pharmacology Year V NIŠ > Pain > Flashcards

Pain Flashcards

1
Q

Why is it beneficial to switch one opioid to another?

A

Increasing dose becomes ineffective
Adverse effects and treatment better balance
Prevent analgesic tolerance

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2
Q

What are the contraindications of acetaminophen?

A

Allergic reactions
Severe liver failure

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3
Q

What are the adverse effects of aspirin?

A

GIT- direct corrosive effects = inhibition of PG synthesis
Hypersensitive- potential cross reaction with other NSAIDs
Risk of bleeding (48 hours)

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4
Q

What is the mechanism of action of beta blockers?

A

Modulation of adrenergic and seratoninergic neurotransmission
In cortical and subcortical pathways
Increases migraine attack threshold

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5
Q

What are the goals of prophylaxis in Migraine management?

A

Decrease frequency and severity of attacks as well as debilitating symptoms
Decrease use of small efficacy drugs
Improve quality of life

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6
Q

Aspirin is a ……… inhibitor

A

Aspirin is a irreversible COX inhibitor

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7
Q

What is the first line drug for mild-moderate pain?

A
  • Naproxen (propionic acid derivative)
    Long half life
    More potent analgesic
    Safest in high risk CVD patients
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8
Q

What drugs are COX-2 coxib inhibitors?

A

Celecoxib
Etoricoxib

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9
Q

When are opioids used for migraines?

A

Rarely used
Possible rebound headache and addiction
If other drug managements are contraindicated
Moderate to severe attacks

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10
Q

When is prophylaxis indicated for Migraines?

A

> 2 attacks/month
Presence of severe or debilitating symptoms
Patients wants to decrease number of attacks
Exaggerated use of abortive therapy drugs

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11
Q

Define pain

A

Unpleasant and subjective experience
Net effect of ascending and descending neurons
Including biochemical, physiological, psychological and neocortical processes

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12
Q

What are the adverse effects of acetaminophen?

A

Liver necrosis- toxic doses, chronic alcoholism and hepatitis
Methemoglobinemia & Hemolytic anaemia in G6PD

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13
Q

What is the function of aspirin?

A

Analgesic
Anti-pyretic
Anti-inflammatory
Decreases nociceptive sensitization and increases pain threshold

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14
Q

What are the types of pain?

A

Neuropathic
Functional
Nociceptive (preventative)
Inflammatory (preventative)

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15
Q

How are migraines managed using non-opioids?

A

Non opioid + Metclopromide
Mild to moderate pain
Most commonly used
Less GIT adverse effects
As effective as sumatriptan and more effective than DHE (Dihydroergotamine)

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16
Q

What is the function of Meloxicam?

A

Oxicam drug class
Selective COX-2 inhibitor
Lower ulcerogenic potential
Long lasting analgesic and anti-inflammatory effects

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17
Q

What are some antiepileptics used in migraine management?

A

Valproic acid and Divalproex - contraindicated in pregnancy and chronic liver disease
Topiramate

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18
Q

What are the adverse effects of Triptans?

A

Drowsiness
Dizziness
Paraesthesia
Sensation of warmth
Chest fullness
Nausea

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19
Q

How do you assess pain?

A

SOCRATES
Number scale 1-10
Patient expectations
Associated Symptoms
Acute or Chronic
Impact of pain on functionality, mental status and behaviour

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20
Q

What is the mechanism of action of antidepressants in migraines?

A

Downregulates 5-HT2 receptors
Increases NA in synapses
Increased effects of endogenous opioids

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21
Q

When can combination therapy be used with opioids?

A

Opioid + Non-opioid
Moderate to severe pain
Enhances analgesia and at lower dose of each
Short acting therapy, therefore not indicated for chronic pain

22
Q

How are dihydroergotamines (DHE) used for migraine management?

A

Early treatment, during the beginning of attacks
Oral administration
Caffeine combination tablets increase absorption and potentiates analgesic effect

23
Q

What is the function of acetaminophen?

A

Analgesic and anti-pyretic
Central analgesic with low potency
Used for mild to moderate pain
Can be used in combination with weak opioids

24
Q

The choice of drug and route of administration for opioids use depends on?

A

Comorbidities
Body mass and age
Intensity and perception of pain
Tolerance to opioids

25
Q

Why convert from one dosage to another in opioids?

A

Ineffective pain control
Side effects emerge
Change in patient status
Formulatory restrictions

26
Q

Why do DHE’s have limited use?

A

Maximum only 2 day use due to risk of fibrosing pleura, pericardium, heart valves and peritoneum

27
Q

What is the plan for migraine prophylaxis?

A

Start with small doses, increase until maximal tolerance or expected efficacy is reached
Change drug if adverse effects emerge or if not efficient
Follow up efficiency every 2-3 months : Migraine Diary

28
Q

What are the adverse effects of opioids?

A

Nausea, constipation, vomiting
Sedation and hallucinations
Respiratory depression- alhtough tolerance develops to this
Constipation tolerance does not develop- laxative must be prescribed in combination e.g. bisacodyl or senna

29
Q

Why are 2nd generation triptans better than 1st generation (Sumatriptan)?

A

E.g. Eletriptan, Frovatriptan, Almotriptan, Naratriptan
Longer half life
Better pharmacokinetics- higher bioavailability
Depending on drug- less adverse effects, more analgesic effect and lower frequency of repeated attacks

30
Q

What type of pain are NSAID’s best suited for?

A

Mild to moderate
Pain mediated by PGs e.g. Rhematoid A, Menstrual cramps and post-surgical pain
Minimal use in neuropathic pain

31
Q

What are the contraindications of coxib COX-2 inhibitors?

A

Pregnancy and breastfeeding
Hypersensitivity
Liver and kidney dysfunction
GIT active bleeding, peptic ulcer and IBD
<16 yrs
Cerebrovascular disease, Peripheral vascular disease etc

32
Q

What are the 3 drug groups used for migraine prophylaxis?

A

Antidepressant, Antiepileptics and Beta Blockers used
Proved efficacy- Metoprolol and valproic acid
Probably efficient- Atenolol and amitriptyline
Possibly efficient- Carbamazepine and pindolol

33
Q

What opioids are used for mild to moderate pain?

A

Codeine
Oxycodone
Hydrocodone
Meperidine

34
Q

What types of antidepressants can be used for migraines?

A

SSRI
SNRI
TCA

35
Q

What is the WHO analgesic ladder for pain management

A

Mild (1-3): non-opioid analgesic
Moderate (4-6): combine acetaminophen/NSAID with moderately potent analgesic
Severe (7-10): high potentcy opioids

36
Q

What is the mechanism of action of Triptans?

A

Strong vasoconstrictor of dilated intracranial arteries
Peripheral neural inhibition
Inhibition of neurotransmission of trigeminal-cervical complex

37
Q

What is opiophobia?

A

Exaggerated concern over opioid use
Risk > Benefit , therefore not prescribed
Although patients are indicated

38
Q

What are the side effects of DHE’s?

A

Chronic headache conversion from chronic use
MI
Ergotism
Nausea & vomiting
Abdominal pain
Diarrhea
Muscle pain and weakness

39
Q

When can combination therapy be used with opioids?

A

Opioid + Non-opioid
Moderate to severe pain
Enhances analgesia and at lower dose of each
Short acting therapy, therefore not indicated for chronic pain

40
Q

When are DHE’s contraindicated?

A

Liver and kidney failure
Cerebral or peripheral vascular disease
Coronary artery disease
Pregnancy
Lactation
Sepsis

41
Q

What is the mechanism of action of antiepileptics in migraines?

A

Increased GABA inhibitory effects
Modulation of glutamate excitatory neurotransmission
Na and Ca channel inhibition

42
Q

How are headaches classified?

A

Primary- migraines, cluster headaches, tension-type headaches and trigeminal autonomic headaches etc.
Secondary- head or neck trauma, infection, vascular or non-vascular intracranial disorders etc

43
Q

What are NSAIDs adverse effects?

A

GIT irritation- dyspepsia, peptic ulcers & bleeding
Nephrotoxicity- hypoperfusion of kidneys
Antiplatelet effect, Na retention, Liver Dysfunction & CNS dysfunction
Increased risk of CVS events

44
Q

What are the contraindications of Triptans?

A

Pregnancy
Lactation
PAD
CAD
MAO inhibitors (including use in previous 2 weeks)
Caution with SSRI or SNRI due to Seretonin Syndrome

45
Q

What is the first line drug for pain?

A
  • Acetaminophen
46
Q

What is the mechanism of action of DHE?

A

Strong arterial vasoconstrictor

47
Q

What are the contraindications of aspirin?

A

III trimester of pregnancy
Risk of bleeding
Allergy
Peptic ulcer
Liver or Kidney dysfunction
Co-medication with methotrexate
Children < 16 yrs
Severe decompensated heart failure

48
Q

What are the contraindications of coxib COX-2 inhibitors?

A

Pregnancy and breastfeeding
Hypersensitivity
Liver and kidney dysfunction
GIT active bleeding, peptic ulcer and IBD
<16 yrs
Cerebrovascular disease, Peripheral vascular disease etc

49
Q

When are triptans indicated for migraine management?

A

Severe or debilitating attacks
Non-specific therapy is ineffective

50
Q

What drugs are acetic acid derivatives?

A

Diclofenac
Ketorolac

51
Q

What opioids are used for moderate to severe pain?

A

Morphine
Oxymorphone
Hydromorphone
Methadone
Fentanyl

52
Q

What are the first, second and third line drugs for neuropathic pain?

A

First line:
Gabapentin
Lidocaine transdermal
TCA e.g. SSRI or SNRI

Second line:
Opioids e.g. tramadol

Third line:
SSRI
Anti-epileptic e.g. carbamezapine, lamotrigine, valproic acid
NMDA anatagonists e.g. Ketamine

Clinical Pharmacology Year V NIŠ (9 decks)

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