PAIN Flashcards
Tylenol + warfarin
Max 2gm/day
Aspirin vs other NSAID MoA
Aspirin irreversibly blocks COX-1 & COX-2
Non-aspirin NSAID Boxed warnings
- GI risk
- CV risk
- CABG surgery (C/I after)
All NSAID ADRs
- Dec. renal clearance by reducing blood flow to the glomerulus
- Inc. BP
- Premature closure of ductus arteriosus leading to HF in baby. Do not use in third trimester (≥ 30 weeks)
- Renal impairment, if used around 20 weeks gestation or later
- Photosensitivity
Ibuprofen max
Rx: 3.2 grams/day
OTC: 1.2 grams/day
Salicylate overdose can cause:
Tinnitus
NSAIDs + lithium
Which NSAID is preferred?
NSAIDs can inc. Li+ lvls
Sulindac is preferred
Codeine: contraindication
< 12 yrs (any indication)
< 18 yrs (following tonsillectomy/adenoidectomy)
When can people begin using fentanyl?
60 MME/day ≥ 7 days
Hydromorphone + MAOIs
2 week washout required
Methadone: warnings
QTc prolongation
CYP450 inhibitors
Serotenergic drugs/MAOIs
Caution in elderly/seizure hx
Which opioid can cause sexual dysfunction?
Methadone
Which opioid can cause hyperhidrosis?
Fentanyl
Methadone
Meperidine
Morphine
Oxycodone
Meperidine: warnings
Renal impairment/Elderly at risk for CNS toxicity
MAOIs (2 wk washout)
Serotonergic drugs
Which opioid can be used if a patient has difficulty swallowing?
Kadian (ER morphine capsules)
Xtampza (ER-Oxycodone-Capsules)
Morphine: IV to PO
10mg IV is 30 mg PO
Which opioid should be taken on a empty stomach?
Oxymorphone
Hydromorphone IV to PO
1.5mg IV is 7.5mg PO
Morphine-to-oxycodone conversion
30mg morphine (PO) is 20mg oxycodone
OIRD risks
- Hx of overdoses
- SUD
- Large doses (≥ 50 MME)
- Use with benzos, lyrica or gabapentin
- Comorbid illness (respiratory or psychiatric disease)
All PAMORAs warnings
GI perforation
C/I in GI obstruction
Tramadol + Tapentadol (Nucynta) MoA
Mu-opioid receptor agonists + NE reuptake inhibitors
Tramadol also inhibits reuptake of 5HT
Tramadol: warnings
- CYP2D6 ultra-rapid metabolizers
- Seizure risk
- Serotonin syndrome
- Hypoglycemia
- C/I in < 12 or < 18 (tonsillectomy/abenoidectomy)
Tapentadol vs tramadol
Tapentadol is a stronger analgesic, hence why its C-II instead of C-IV
Lioresal: Boxed warning
Acute withdrawal of intrathecal baclofen = organ failure/death
Cyclobenzaprine: D/I
serotonergic
Common migraine triggers
- Hormonal changes
- Foods
- Stress
- Sensory stimuli (bright lights, scents, noises)
- Changes in sleep-wake pattern
- Changes in environment (weather, bariometric pressure)
Migraine: diagnosis
5+ attacks fulfilling the following criteria:
1. lasting 4-72 hrs and recur sporadically
2. ≥ 2 characteristics: unilateral location, pulsating, moderate-severe pain, aggravated by (or causing avoidance of) routine physical activity
3. One of the following during the headache: N/V, photophobia, phonophobia
Natural products used for headaches
Riboflavin
Magnesium
Butterbur
Feverfew
Peppermint (locally)
Co-Q-10
Medication Overuse Headaches: definition
Occur > 10-15 days/month
To prevent MOH
limit acute treatment to 2-3 times/week
Triptans C/I + warnings
CVD (stroke/TIA)
Uncontrolled HTN
IHD, PVD
Within 24 hrs of an ergogamine
Serotonin syndrome
Formulations to use if nausea if present with migraine
Nasal, ODTs, Injections
Longer lasting triptans
Frovatriptan (longest half-life with 26 hrs)
Naratriptan
Slower onset, use if HA recurs after dosing or can be anticipated
ODT triptans
Rizatriptan (Maxalt-MLT)
Zolmitriptan (Zomig-MLT)
Nasal spray/powder triptans
Imitrex
Zomig
Onzetra Xsail (powder)
SC injection triptans
sumitriptan
Imitrex STATdose, Zembrace SymTouch (autoinjector)
Ergotamine MoA
nonselective 5HT receptors agonist
Migranal (Dihydroergotamine) warnings/CI
- Potent CYP3A4 inhibitors (d/t peripheral ischemia)
- Uncontrolled HTN
- IHD, MI, PVD
- Pregnancy
- Within 24 hrs of triptans
- Within 2 weeks of MAOIs
Lasmiditan (Reyvow) MoA
Selective 5-HT1F receptor subtype agonist DOES NOT cause vasoconstriction
When should you consider prophylactic treatment for migraines?
acute treatments ≥ 2 days/week or ≥ 3 times/month, migraines dec. QoL, ineffective acute treatments, pt requests it
Atogepant (Qulipta): dosing
PO daily
Epinezumab-jjmr (Vyepti)
IV every 3 months
Erenumab-aooe (Aimovig)
SC monthly
Fremanezumab-vfrm (Ajovy)
SC monthly or higher dose 675 mg every 3 months
Galcancezumab-gnlm (Emgality)
SC monthly
Rimegepant (Nurtec)
ODT every other day
Triptans ADRs
somnolence (sleepiness, not activation), nausea, paresthesias (tingling/numbness), throat/neck pressure, dizziness, hot/cold sensations, chest pain/tightness