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PHRM 845 Exam 5 > Pain > Flashcards

Pain Flashcards

1
Q

Aspirin

A

acetylation and irreversible inactivation of COX-1

may modify COX-2 activity by producing lipoxins (lipid mediators)

No tolerance development for analgesic effects

Rapidly absorbed: delayed by presence of food
Passive diffusion of unionized acid at gastric pH

Distribution: competes with many drugs for protein binding sites

Renally eliminated by active secretion and passive reabsorption in renal tubule

Increased excretion with increased urinary pH–> IV bicarb for overdose

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2
Q

3 phases of inflammatory response

A

Acute: vasodilation leading to increased permeability

Subacute: infiltration
Mediators recruit inflammatory cells
Eicosanoids–> arachidonic metabolites–> prostaglandins (redness, swelling,pain)–> thromboxane–> leukotrienes (sweating)–> cytokines (pain)

Chronic: proliferation

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3
Q

Side effects of Aspirin

A

GI bleeding

Hematologic bleeding

Reye’s syndrome: swelling in liver and brain

Associated with < 18 yo when having viral infections (flu/chickenpox)

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4
Q

Salicylism/Aspirin poisoning

A

Mild: vertigo, tinnitus, hearing impairment

CNS: respiratory alkalosis, metabolic acidosis

Reduce salicylate load:
Dextrose or sodium bicarb: increase urinary excretion

Traps salicylate in urine at pka of 3.0-> ionized

correct metabolic imbalance

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5
Q

Ibuprofen

A

Arylpropionic acid

T1/2: 2 hr

Formulations: tablet, capsule, IV solution, suspension, chewable

Dosing adults: 200-800 mg q4-6 hr PRN–> max 3200 mg/day

Pediatrics: 5-10 mg/day q4-6 hr PRN–> max 40 mg/kg or 2400 mg/day

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6
Q

Naproxen

A

Arylpropionic acid

Reversible inhibitors of COX1/2

Formulations: tablet, ER/DR tablet, capsule, suspension

Dosing: 220-500 mg q6-12 h–> max 1000 mg/day

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7
Q

Diclofenac

A

Voltaren

Tablet, capsule, IV, suppository, topical gel, topical solution, ophthalmic solution, patch

50 mg q8h or 2-4 g applied QID

increase risk of peptic ulcer and renal dysfunction
minimal systemic side effects with topical gel

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8
Q

Indomethacin

A

Most potent: high incidence and severity of side effects

Indications: gouty arthritis, ankylosing spondylitis

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9
Q

Sulindac

A

less toxic derivative of indomethacin

Rheumatoid arthritis
Ankylosing spondylitis

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10
Q

Meloxicam

A

enolic acid NSAID

COX-2 selective at low doses

SE: low GI

arthritis
T1/2: 20 hrs

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11
Q

Side effects of NSAIDS

A

Peripheral edema: Inhibits PGE2 synthesis leading to increased Na reabsorption

Nephrotoxicity
GI bleeding
GI distress/ulcers: Misoprostol PGE1 analog protects lining of stomach

Increase CV events
Inhibition of uterine motility

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11
Q

Piroxicam

A

arthritis

SE: low GI

T1/2 57 hrs

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12
Q

NSAID contraindications

A

CKD
Peptic ulcer disease
Hx of GI bleeding
CV risk: lowest with naproxen, highest with diclofenac
Disrupted bone healing
Asthma exacerbation: Less likely with COX-2 selective

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13
Q

Pearls of NSAIDS

A

Take with food
Caution in geriatric patients
Avoid systemic NSAIDS with CV hx
Avoid in severe renal/hepatic impairment

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14
Q

Celecoxib

A

Celebrex

Arthritis

Capsule, oral solution

Dosing: 200 mg BID

Advantages: reduce ulcers and GI bleeds

Disadvantages: BLACK BOX: increase risk of MI, strole, blood clots

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15
Q

Acetaminophen

A

Tablet, capsule, chewable, liquid/gel, IV, suppository

Advantages: No GI toxicity, No platelet aggregation, no Reye’s syndrome

Disadvantages: No anti-inflammatory, hepatic necrosis

SE: renal toxicity, papillary necrosis
vasoconstriction by inhibition of PGE2
greater than aspirin/NSAIDS

Hepatic necrosis: increase risk with alcohol
Treatment: n-acetylcysteine to detoxify NAPQI

GOLD STANDARD FOR OSTEOARTHRITIS

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16
Q

Venlafaxine

A

fibromyalgia, neuropathies

tablet (ER), capsule (ER)

37.5-75 mg/day–> Max 225 mg/day

SE: increased BP, nausea, sedation, weakness

Renally eliminated

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17
Q

Duloxetine

A

fibromyalgia, neuropathies

tablet (ER), capsule (ER)

30 mg po daily for 1 weeks then increase to 60 mg po daily–> max 60 mg/day

SE: increased BP, nausea, sedation, weakness

Renally eliminated
Avoid if CrCl is < 30 mL/min

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18
Q

Amitriptyline/Nortriptyline

A

Fibromyalgia, neuropathies

Tablet (A), capsule (N), oral solution (N)

A/N: 10 mg po QHS–> max is 150 mg/day

SE: sedation, anticholinergic

Pearls: last line for fibromyalgia and neuropathies

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19
Q

Muscle relaxants

A

muscle spasms

Tablet/capsule (IR/XR)
Oral solution (Baclofen)
IV solution (methocarbamol, baclofen)

SE: anticholinergic

Pearls: short-term use < 3 weeks

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20
Q

Cyclobenzaprine

A

5 mg TID–> Max 30 mg/day

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21
Q

Baclofen

A

5 mg TID–> Max 80 mg/day

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22
Q

Carisoprodol

A

250-350 mg TID–>Max 1050 mg/day

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23
Q

Methocarbamol

A

1.5 g TID/QID–> Max 8g/day

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24
Q

Tizanidine

A

2-4 mg q8012h–> max 24 mg/day

25
Q

Carbamazepine

A

neuropathies

Tablet (ER), capsule, chewable, suspension

200-400 mg PO daily in 2-4 divided doses–> Max 1200 mg/day

caution with HLA-B1502 and HLA-A3101–> hypersensitivity

CYP3A4 inducers

26
Q

Lidocaine

A

sodium channel blocker

local analgesia, itch, burn

Patch (4% OTC, 5%), injection, topical

Onset 15 min

Duration 30-120 min

Apply 1 patch and remove after 12 hours

SE: hypotension, arrhythmia

Tachyphylaxis with continued use–> 12 hr free period

27
Q

Bupivacaine

A

Na channel blocker

Epidural anesthesia

Duration: 3.5 hours

28
Q

Benzocaine

A

oral ulcer, ear pain

SE: hypersensitivity

29
Q

Capsacian

A

muscle/joint pain, neuropathies

Cream, gel, lotion, liquid, patch

Apply 3-4 times daily or apply 1 patch and remove after 8 hours

Skin irritation, pain

Wash hands, do not get medication in eye

30
Q

NSAIDS/Aspirin in geriatrics

A

increase GI bleed and PUD
increase BP and AKI

Recommend to avoid short/chronic use unless alternatives are not effective and pt can take PPI/Misoprostol

31
Q

Indomethacin/ketorolac in geriatrics

A

increase risk of GI bleed and PUD

Increase risk of AKI

Recommendation: AVOID

32
Q

Muscle relaxants in geriatrics

A

anticholinergic and risk of falls/fractures

Recommendations: AVOID

33
Q

SNRI/TCA/Carbamazepine in geriatrics

A

increase risk of hyponatremia/SIADH

monitor Na levels

Recommendation: CAUTION

34
Q

Opioids + Benzodiazepines in geriatrics

A

increase risk of overdose/misuse

Recommendation: AVOID

35
Q

Opioids + Gabapentin/Pregabalin in geriatrics

A

increase risk of sedation and respiratory depression

Recommendation: AVOID

UNLESS: transitioning from opioid to gabapentinoid OR using gabapentinoid to reduce opioid use

36
Q

Antiepileptics + SSRN/SNRI + Antipsychotics + BZDs + Z drugs + Opioids in geriatrics

A

increase risk of falls/fractures with 3 or more CNS agents

Recommendation: AVOID 3 or more CNS agents

37
Q

Opioid agonists/antagonist

A

Opioid antagonist: naltrexone

Weak agonist: codeine, tramadol

38
Q

Natural opiates

A

codeine, morphine

39
Q

Semi-synthetic opiates

A

hydromorphone

oxymorphone

hydrocodone

oxycodone

buprenorphine

40
Q

Synthetic opiates

A

tramadol

fentanyl

methadone

meperidine

41
Q

Codeine (Tylenol #3)

A

prodrug

Tablet, cough syrup

15-60 mg q4h PRN

Metabolized to morphine by CYP2D6

Poor metabolizers: no effect from codeine

Ultra rapid metabolizers: overdose

Not recommended in children < 12 or breastfeeding mothers

42
Q

Tramadol

A

Tablet (IR/ER), Capsule (ER), ORAL SOLUTION

25-50 mg q4-6h PRN

Schedule 4 drug
Renally eliminated
Risk of serotonin syndrome

Box warning: CYP3A4/2D6 inhibitor and 3A4 inducers require consideration on effects of drug and metabolite

43
Q

Morphine

A

Tablet (IR/ER), Capsule (ER), oral solution, IM/IV/SQ, suppository

Oral: 5-10 mg q4h PRN
IV: 2.5-5 q3-4h PRN

ITCHING
Avoid in CKD stage 4 or 5 and AKI
Renally eliminated

Avoid taking alcohol with ER capsules–> increase plasma levels

44
Q

Hydromorphone

A
45
Q

Hydrocodone +/- acetaminophen

A

Tablet (ER), oral solution

2.5-10 mg q4-6h PRN

Counsel patients on acetaminophen use

Box warning: CYP3A4 inhibitors can increase concentration

46
Q

Oxycodone +/- acetaminophen

A

Tablet (IR/ER), Capsule (IR/ER), oral solution

5-15 mg q4-6h PRN

Counsel on acetaminophen use

ER is abuse-deterrant

CYP3A4 inhibitors can increase concentration

47
Q

Fentanyl

A

Lozenge, buccal, sublingual liquid, IM/IV, patch

25-50 mcg q30-60 min PRN

Patch: use table to go from morphine to fentanyl
cannot go from fentanyl to morphine–> OVERDOSE

Fast on, fast off
Less hypotension than morphine/hydromorphone

Non-injectable are only for opioid tolerant

Opioid tolerant: morphine 60 mg/day for 1 week

Box warning: CYP3A4 inhibitors/inducers

48
Q

Fentanyl patch counseling

A

Apply patch every 72 hours

Apply to chest, back, flank, arm

Do not cute patch are use torn/damaged patch

Do not place patch on broken skin

Do not let patch get too warm

You can shower with patch

49
Q

Methadone

A

tablet, oral solution, IV/IM

Long T1/2: 8-59 hrs
Box warning: QTc prolongation
Box warning: CY3A4 inhibitors/inducers

50
Q

Symptoms of overdose

A

Sedation/loss of consciousness

Constricted pupils

decreased respiratory rate

bradycardia

hypotension

pale, clammy skin

51
Q

Symptoms of withdrawal

A

Insomnia/agitation

dilated pupils

increased respiratory rate

tachycardia

hypertension

sweating

52
Q

Naloxone

A

Opioid antagonist

IV: 0.4-2 mg q2-3min
Nasal spray: 4 mg q2-3min

SE: opioid withdrawal

Prescribed with opioids IF:
Hx of overdose, SUD
High doses (>50 morphine mg equivalents/day)
Concurrent use with benzos

53
Q

How to taper opioids

A

Avoid abrupt tapering or sudden d/c

If opioid > 1 year reduce dose by 10% per month

If opioid < 1 year reduce dose by 10% per week

54
Q

Opioid withdrawal

A

short-acting: 8-24 hours lasting 4-10 days
long-acting: 12-48 hours lasting 10-20 days

clonidine
buprenorphine
methadone

55
Q

Chronic low back pain

A
  1. Tylenol or NSAID
  2. SNRI or TCA
56
Q

Chronic osteoarthritis

A
  1. Tylenol or NSAID (oral or topical)
  2. Hyaluronic acid injection or capsaicin
57
Q

Chronic fibromyalgia

A
  1. Pregabalin or Duloxetine
  2. Venlafaxine, gabapentin, TCA
58
Q

Chronic neuropathic pain

A
  1. SNRI or Gabapentin/pregabalin
  2. Lidocaine or TCA
59
Q

Buprenorphine

A

Usually combined with Naloxone in SL tablet/film

Initiate therapy when there are clear signs of withdrawal
Administer in divided doses on day 1

SE: hepatotoxicity, serotonin syndrome, low risk of respiratory depression (partial agonist)

X-waiver from prescribers has been removed

Extended-Release Injection–>Sublocade, Brixadi
Patients must be on SL tablet for at least 7 days prior to first injection

REMS

60
Q

Methadone for tx of withdrawal

A

must be given in a licensed treatment program

61
Q

Naltrexone injection for withdrawal

A

Same dose as alcohol withdrawal

Fully blocks opioid receptor–>abstinence treatment

Risk for overdose if patient d/c treatment

PHRM 845 Exam 5 (13 decks)

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