Pain Flashcards
acetaminophen
Tylenol, FeverAll (rectal suppository), Ofirmev (injection)
max 4,000 mg
avoid APAP abbreviation
acetaminophen + hydrocodone
Lorcet, Lortab, Norco, Vicodin
acetaminophen
+ codeine
tylenol #2, 3, 4
acetaminophen
+ caffeine
Excedrin tension headache
acetaminophen
+ aspirin/caffeine
Excedrine Extra strngth, Excedrine Migraine
acetaminophen
+ caffeine/pyrilamine
Midol Complete
acetaminophen
+ Butalbital/Caffeine
Fioricet
cox-1 and cox-2 non-selective NSAIDs
all agents have GI risk, CV risk in post-operative CABG setting`
Ibuprofen
Indomethacin
Naproxen
Ketorolac
Ibuprofen
Advil, Caldolor, Motrin IB
Indomethacin
Indocin
OTC self- tx days? ibuprofen
also notes
less then 10
IV injection is indicated for closure of PDA in premature infants
severe skin reaction including SJS
notes high risk in indomethacin
CNS side effects especially in psych conditions… (think of the depression chapter)
IV injection is indicated for the closure of PDA in premature infants
NSAIDs and the Ductus Arteriosus (DA)
Do not use NSAIDs in the third trimester of prego can cause the premature closure of DA
IV NSAIDs (indomethacin, Ibuprofen) can be used within 14 days after birth to close a patent ductus arteriosus (PDA)
naproxen
aleve
naproxen
+ esomeprazole
Vimovo
Katerolac
Toradol, Acular (ophthalmic), Sprix (Nasal Spray)
usually used after surgery never before if that’s the case..
Sprix
katerolac nasal spray
prime five times before use and discard 24 hrs after opening
max duration of Katerolac
5 days
NSAIDS GI risk
increases the risk of serious GI adverse events, including bleeding and ulceration.
Elderly, and pt taking systemic steroids, SSRIs and SNRIs are at greatest risk
CV risk NSAIDs and renal
Risk of MI and stroke avoid use in pt w/ CV disease or risk factors. except aspirin
can decrease renal clearance by reducing blood flow
Aspirin is an
irreversible cox 1 cox 2 and is an effective antiplatelet agent that provides CV benefit
increased cox 2 selective
lower risk for GI complications (but still present). Increased risk MI/stroke (avoid w/ CV risk, avoid increased dose and longer duration in pt at risk for CV disease), the same risk for renal complications
celecoxib
diclofenac
meloxicam
Nabumetone
celecoxib
Celebrex
celecoxib
+ amlodipoine
+ tramadol
consensi
seglentis
celecoxib
notes and contra
contra: sulfa allergy
highest cox-2 selectivity
avoid prego: risk greatest at >= 30 weeks gestation
severe skin reaction…
diclofenac
voltaren (gel) otc
diclofenac
+ misoprostol
arthrotec
avoid in females of childbearing potential… can increase uterine contractions (abortifacient)
but misoprostol is used to replace the gut-protective prostaglandins
meloxicam
mobic
aspirin/acetylsalicylic acid
ascriptin, Bufferin, Ecotrin: EC/buffered
aspirin
+ omeprazole
Yosprala
Durlazo and Yosprala are slow releases, do not use if you need an immediate effect
Durlazo
ER capsule
aspirin
Durlazo and Yosprala are slow releases, do not use if you need an immediate effect
Warning w/ salicylates NSAIDs
- hypersensitivity reaction risk, including SJS
- AVOID aspirin in children and teenagers w/ any viral infection due to the potential risk of Reye’s syndrome! (symptoms: somnolence, N/V, lethargy, confusion)
- avoid third trimester of prego
- GI bleed and ulceration
Magnesium salicylate
non-acetylated salicylates
Doan’s extra strenght
salicylate overdose can cause
tinnitus!
also:
aspirin w/ other ototoxic agents (e.g. aminoglycosides, IV loop diuretics).. can increase tinnitus risk
codeine
codeine + acetaminophen
codeine tablets- C-II
combo products tablets/capsules- C-III
Tylenol #2, 3, 4
key things about codeine
FDA avoid in <18 cold and cough products w/ codeine
ultra-rapid metabolizers be careful or avoid especially lactating women
fentanyl
duragestic, sublimaze
atiq: oral transmucosal lozenges on a stick “loollipop”
lazanda: nasal spray
subsys: spray, SL
fentora: buccal tabs
use of fentanyl
if outpatient, chronic pain management only
not used in opioid-naive pts
pt who has been using equivalent to morphine 60 mg/day or more for 7 days!
short t1/2 when given IV
atiqu disposal
cut off the stick and flush unused/unneeded doses
transmucosal IR fentalny requires
REMs program and documentation of patient’s opioid tolerance w/ each prescription
fentanyl patch use
- effect seen up to 8-16 hrs. d/c all around the clock opioids drugs when the patch is applied
- apply to hairless skin (cut hair if needed)
- do not apply > 1 patch at a time
- can only be covered w/ adhesive film dressing Bioclusive or tegaderm
- removed before MRI
- dispose of patch in toilet
hydrocodone IR (combo products only)
warning and notes
+ acetaminophen (Vicodin, norco…)
+ chlorpheniramine (tussiCaps)
warning: Cyp3A4 substrate!!!!!!
notes: do not use <18
hydrocodone ER
warning:
Note:
Zohydro ER (capsule), Hysingla ER (tablet)
Warning: Cyp3A4 substrate!!!!!!
Note: preferably avoid use if breasting, abuse-deterrent formulations
Hysingla ER
Note:
QT prolongation has occurred at doses >160mg/day
hydromorphone
Dilaudid: 1mg/ml
high potency injections (HP)- risk for medication error, use ONLY in opioid-tolerant pt 10mg/ml
methadone
dolophine
methadone box warnings and notes
box warning: QT prolongations!
Notes: variable half-life
Meperidine
Demerol
meperidine warnings and notes
warning: renal impairment/elderly at risk for CNS tox. avoid w/ or within 2 weeks of MOA
Notes: NO LONGER recommended for analgesic
metabolite normeperidine. renally cleared! accumulation leads to CNS tox and seizures
Morphine ER
MS Contin, Kadian
Morphine injection
Duramorph, Infumorph
Oxycodone IR
Roxicodone, Oxaydo
warning: cyp3A4 substrate!!!
Oxycodone CR, ER
OxyContin (CR), Xtampza (ER)
warning: cyp3A4 substrate!!!
Oxycodone + acetaminophen
Endocet, Percocet
warning: cyp3A4 substrate!!!
oxycodone abuse-deterrent formulations
Oxaydo, OxyContin, Xtampza ER
Xtampza ER caps note
can be opened up and content can be administered w/ soft food or through a gastric tube
oxycodone notes:
avoid high fat meals w/ higher dose (except re-formulated OxyContin)
if renally impaired start a lower dose or avoid oxycodone due to accumulation of parent and /or active metabolite
oxymorphone
Opana
do not use w/ moderate-to-severe liver impairment!
take on empty stomach!
conversion
drug IV/IM(mg) oral(mg)
morphine 10 30
Hydromorphone 1.5 7.5
oxycodone _ 20
hydrocodone _ 30
codeine 130 200
fentanyl 0.1 _
Meperidine 75 300
Oxymorphone 1 10
genal opioid box warning
- addiction abuse and misuse can lead to overdose and death
- respiratory depression can be fatal
- use of any opioids w/ benzo, CNS depressants, including OH can increase the risk of death
-** Kadian, Nucynta ER, Oxymorhone ER, and Zohydro ER: DO NOT consume with -OH! can increase drug plasma levels, which can lead to a potentially fatal overdose ** - accidental ingestion/exposure of even one dose can be fatal to children
- crushing, dissolving or chewing of the long-acting products can cause delivery of potentially fatal dose
- life-threatening neonatal opioid withdraw w/ prolong use during prego
acetaminophen overdose
- tx: N-acetylcysteine (NAC, acetadote)
- it increases glutathione precursor
- Rumac-Mathew nomogram for dosing
which opioids use w/ OH specifically avoid even though avoid with all
- Kadian, Nucynta ER, Oxymorhone ER, and Zohydro ER: DO NOT consume with -OH! can increase drug plasma levels, which can lead to a potentially fatal overdose
opioid allergy cross-react
cod or morph (except buprenorphine has norph)
CODeine MORPHine
HydroCODone HydroMORPHone
OxyCODone OxyMORPHone
bupreNORPHine
Heroin (diacetyl-morphine)
opioid-induced constipation (OIC)
stimulant laxatives (including senna) first line
bisacodyl tablet for prophylaxis or suppository for tx
can use PAMORAs for only opioid-induced constipation
peripherally-acting mu-opioids receptor antagonists (PAMORAs)
can try lubiprostone
Methylnaltrexone
Relistor
contra: GI obstruction
warning: GI perforation
stay close to toilet after injection lol
d/c all laxatives prior to use…
only use when otc laxative failed
- PAMORAs
Naloxegol
Movantik
contra: GI obstruction, strong cyp3A4 inhibitors
warning: GI perforation
d/c all laxatives prior to use, can reintroduce if suboptimal response after 3 days
- PAMORAs
lubiprostone
amitiza
tramadol
ultram
- seizure risk, serotonin syndrome risk (MOA avoid or 14 days..)
- boxed warning: serious risk w/ ultrarapid metabolizers (risk in breastfeeding mothers)
- do not use in <12 and <18 if tonsillectomy/adenoidectomy surgery
tapentadol
Nucynta
- seizure risk, serotonin syndrome risk (MOA avoid or 14 days..)
- stronger than tramadol
Narcan
onset of actin is slower than injection, 4mg one nostril and if needed to re-dose, use the other nostril
Naloxone
injection
2-3 min redose if needed
Buprenorphine
belbuca (bucal film), butrans (patch)
subclade: once monthly injection- pt must be on a stable dose for 7 days
buprenorphine
+ naloxone
suboxone (sublingual film)
zubsolv (sublingual tab)
buprenorphine warning: and what do prescribers need?
QT prolongation (>20mcg/hr, CNS depression, and severe dental AE with oral formulations…
prescribers need the X number: drug addiction treatment act
gabapentin
Neurontin
gralise tab: for PHN
gabapentin enacarbil
Harizant ER: for Postherpetic neuralgia (PHN) (think of shingles pain….) and restless legs syndrome
take w/ food
gabapentin
warnings and notes
warning: increase seizure frequency if rapidly stoped
notes: off-label use fibromyalgia, pain (neuropathic), headache, drug abuse, alcohol withdrawal
IR, ER, and gabapentin encarbil are not interchangeable
pregabalin
lyrica
warning: increase seizure frequency if rapidly stoped
notes: provided use in fibromyalgia, PHN and neuropathic pain associated w/ diabetes and spinal cord injury
carbamazepine
Tegretol
only FDA-approved medications for the tx of trigeminal neuralgia
baclofen
Lioresal
boxed warning: abrupt withdrawal of intrathecal baclofen has resulted in severe effects (high fever, lethargy, rebound/increased capacity, muscle rigidity and rhabdomyolysis) leading to organ failure and death
cyclobenzaprine
Amrix, Fexmid, Flexeril
serotoninergic, do not combine w/ other serotonin agents
can cause arrhythmias….
tizanidine
zanaflex
centrally acting alpha-2 agonist
