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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
Tizanidine
2-4 mg q8012h--> max 24 mg/day
25
Carbamazepine
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
Lidocaine
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
Bupivacaine
Na channel blocker Epidural anesthesia Duration: 3.5 hours
28
Benzocaine
oral ulcer, ear pain SE: hypersensitivity
29
Capsacian
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
NSAIDS/Aspirin in geriatrics
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
Indomethacin/ketorolac in geriatrics
increase risk of GI bleed and PUD Increase risk of AKI Recommendation: AVOID
32
Muscle relaxants in geriatrics
anticholinergic and risk of falls/fractures Recommendations: AVOID
33
SNRI/TCA/Carbamazepine in geriatrics
increase risk of hyponatremia/SIADH monitor Na levels Recommendation: CAUTION
34
Opioids + Benzodiazepines in geriatrics
increase risk of overdose/misuse Recommendation: AVOID
35
Opioids + Gabapentin/Pregabalin in geriatrics
increase risk of sedation and respiratory depression Recommendation: AVOID UNLESS: transitioning from opioid to gabapentinoid OR using gabapentinoid to reduce opioid use
36
Antiepileptics + SSRN/SNRI + Antipsychotics + BZDs + Z drugs + Opioids in geriatrics
increase risk of falls/fractures with 3 or more CNS agents Recommendation: AVOID 3 or more CNS agents
37
Opioid agonists/antagonist
Opioid antagonist: naltrexone Weak agonist: codeine, tramadol
38
Natural opiates
codeine, morphine
39
Semi-synthetic opiates
hydromorphone oxymorphone hydrocodone oxycodone buprenorphine
40
Synthetic opiates
tramadol fentanyl methadone meperidine
41
Codeine (Tylenol #3)
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
Tramadol
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
Morphine
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
Hydromorphone
45
Hydrocodone +/- acetaminophen
Tablet (ER), oral solution 2.5-10 mg q4-6h PRN Counsel patients on acetaminophen use Box warning: CYP3A4 inhibitors can increase concentration
46
Oxycodone +/- acetaminophen
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
Fentanyl
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
Fentanyl patch counseling
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
Methadone
tablet, oral solution, IV/IM Long T1/2: 8-59 hrs Box warning: QTc prolongation Box warning: CY3A4 inhibitors/inducers
50
Symptoms of overdose
Sedation/loss of consciousness Constricted pupils decreased respiratory rate bradycardia hypotension pale, clammy skin
51
Symptoms of withdrawal
Insomnia/agitation dilated pupils increased respiratory rate tachycardia hypertension sweating
52
Naloxone
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
How to taper opioids
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
Opioid withdrawal
short-acting: 8-24 hours lasting 4-10 days long-acting: 12-48 hours lasting 10-20 days clonidine buprenorphine methadone
55
Chronic low back pain
1. Tylenol or NSAID 2. SNRI or TCA
56
Chronic osteoarthritis
1. Tylenol or NSAID (oral or topical) 2. Hyaluronic acid injection or capsaicin
57
Chronic fibromyalgia
1. Pregabalin or Duloxetine 2. Venlafaxine, gabapentin, TCA
58
Chronic neuropathic pain
1. SNRI or Gabapentin/pregabalin 2. Lidocaine or TCA
59
Buprenorphine
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
Methadone for tx of withdrawal
must be given in a licensed treatment program
61
Naltrexone injection for withdrawal
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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