Pain Flashcards
patho, non-opioids, opioids, opioid overdose, OUD, common adjuvants, key counseling points
adjuvant pain management examples
ADs
AEDs
muscle relaxers
non-opioid pain management examples
NSAIDs
APAP
BBW for APAP
hepatotoxicity with doses >4g
adult dosing for APAP
325mg: 2t q4h / MDD 10t
500mg: 2t q6h / MDD 6t
650mg ER 2t q8h / MDD 6t
general MDD = 4,000mg
what is the max permissible amount of APAP allowed in combination products
325mg
what is the pediatric dosing for APAP
10-15mg/kg q4-6h
MDD = 5 doses
what nomogram is used in APAP overdose to determine the likelihood of hepatotoxicity and need for NAC?
Rumack-Matthew nomogram
uses APAP Cp and time
COX-1 vs COX-2
COX-1 protects the gastric mucosa
COX-2 converts arachadonic acid to PG + TXA2
what are the non-selective NSAIDs
ibuprofen
naproxen
ketorolac
indomethacin
what are the COX-2 selective NSAIDs
celecoxib
meloxicam
diclofenac
what are the six main SE of NSAIDS
- dec renal BF leading to dec renal CL: caution in renal failure or use with nephrotoxins
- inc BP: avoid in uncontrolled HTN
- can cause premature closing of the ductus arteriosus leading to HF in baby: do NOT use NSAIDs in the 3rd trimester
- GI bleed
- nausea
- photosensitivity
ibuprofen dosing in adults
OTC: 200-400mg po q4-6h MDD 1.2g
Rx: 600-800mg po q6-8h MDD 3.2g
ibuprofen peds dosing
10 mg/kg/dose q6-8h
MDD 40mg/dose
if a patient is taking OTC ibuprofen, what is the max # of days they should take it for
10 days
brand name for ibuprofen form used to close the DA in newborns
Neoprofen
NSAIDs ______ and _______ are used to close the DA in newborns
ibuprofen (Neoprofen) and Indomethacin
bothIV
Naproxen OTC dosing
200mg q8-12 hours MDD 600mg
Naproxen Rx dosing
500mg q12h MDD 1000mg
Treximet is
naproxen + sumatriptan
Vimovo is
naproxen + exomeprazole
Naproxen base __mg = naproxen Na ___mg
base 200mg = 220mg Na
Celecoxib dosing
100-200mg daily-BID
Which NSAID is CI in sulfa allergy
celecoxib
Celecoxib approved uses
RA
OA
juvenile RA
acute pain
primary dysmenorrhea
ankylosing spondylitis
which NSAID has the highest COX-2 selectivity
calecoxib
indomethacin should be avoided in patients with
psych diagnoses 2/2 CNS adverse effects
indomethacin IR typically used for
gout!
Ketorolac
band name
dosing
toradol
po 10-20mg x1 then 10mg q4-6h prn
iv 30mg x1 or 30mg q6h
excedrin contents
APAP/ASA/caffeine
ketorolac BBW: max duration of therapy of all combined dosage forms
5 days
when in pregnancy should NSAIDs especially be avoided
3rd trimester (30 weeks gestation)
NSAIDs interact with
blood thinners
ototoxins
other NSAIDs
NSAIDs increase plasma concentrations of (SATA)
A. Lithium
B. rifampin
C. warfarin
D. MTX
E. carbamazepine
A. Lithium
D. MTX
opioid BBW
- addiction abuse and misuse
- resp dep, possibly fatal
- inc risk of death when combined with benzo, etOH, CNS depressants
- absolutely no alcohol with ER forms
- accidental exposure to children can be fatal
- crushing LA products can cause fatal overdose
- life-threatening neonatal withdrawal if used during gestation
fentanyl patch
what are the criteria to be on a patch
how is the patch used
need to be on at least 60mg morphine or equivalent for >/= 7 days
patch is once q72h and can be covered with Tegaderm or Bioclusive
fentanyl brand names
duragesic, sublimaze
hydromorphone
brand
dosing
dilaudid
po 2-4mg q4-6h
iv 0.2-1mg q2-3h
BBW for fentanyl
dosing conversion errors
use with strong 3A4-i
methadone
brand
SE
dolophine
QTp
serotonin syndrome
3A4 substrate
codeine is a C-___
codeine w APAP is a C-___
codeine solutions are C-__
codeine is a C-II
codeine w APAP is a C-III
codeine solutions are C-V
codeine is metabolized to morphine via
2D6
codeine-specific BBW
BBW in children due to 2D6 polymorphisms of rapid metabolizers to morphine
codeine is contraindicated in
brastfeeding
<12
<18 for post-op tonsillectomy or adenectomy pain
tylenol #3 contents
codeine 30mg / APAP 300mg
tylenol #4 contents
codeine 60mg / APAP 300mg
hydrocodone cold preparations are not for use in
<18 yo
morphine brand names
ER = Ms Contin
inj = duramorph, infumorph
oxycodone brand names
IR = roxicodone
ER = oxycontin
ER w APAP = percocet, endocet, Xtamza ER
74 yo female patient reports to pain manage for post operative back pain after a knee surgery. PMH sig for COPD on LABA/LAMA/ICS, depression on sertraline and mirtazepine, OA on APAP and GERD on PPI
provider wants to initiate opioid for pain management. what are the concerns?
elderly patient - inc fall risk, fractures, renal function
COPD - inc risk hypoxemia 2/2 resp depression
which opioids are CYP3A4 substrates and should be avoided with 3A4-i
hydrocodone
fentanyl
methadone
oxycodone
how do we convert from one opioid to the other
1) calculate the total daily dose of drug A
2) using the opioid equivalence chart, convert to the other opioid (Drug B)
3) DECREASE dose of Drug B by 50% to account for cross tolerance
4) split new total daily dose of Drug B into appropriate regimen (BID, TID, etc.)
5) BTP is 10-15% of the TDD once q1-2h
opioid dose equivalents
——————-IV/IM (mg)————-po (mg)—
morphine 10 30
hydromorphone 1.5 7.5
oxycodone 20
hydrocodone 30
first line for opioid-ind constipation
stimulant (bisacodyl, senna) or
osmotic (PEG) laxitives
second line for opioid-ind constipation
naloxegol (Movantik)
Lubipristone (Amitiza)
methylnaltrexone (relistor)
tramadol
brand
Ultram
what CI do tramadol and codeine share
avoid in <12
avoid in <18 for post-op tonsillectomy or adenectomy pain
tramadol warnings
similar to methadone
seizure risk, serotonin syndrome risk
tapentadol
brand names
nucynta IR and ER
warnings for tramadol and tapentadol
avoid MAO-i within 14 days
poss increased INR w warfarin
caution with seizures
caution with serotonergics
avoid tramadol w 2D6 inhibitors
gabapentin dosing
300mg PO TID MDD 3600mg
when does gabapentin dose need to be adjusted
CrCl <60
when does pregabalin dose need to be adjusted
CrCl <60
off-label gabapentin uses
FM, neuropathy, HA, AUD, alcohol withdrawal
FDA approved doses for pregabalin
FM, PHN, neuropathic pain 2/2 DM or sp cord injury
pregabalin dosing
75mg BID or 50mg TID
MDD 450mg
carbamazepine
brand
dosing
FDA approval
Tegretol
100mg BIG, MDD 1200mg
FDA approved for trigeminal neuralgia
