Pain Flashcards
When can APAP be used in elderly patients?
OA
Low back pain
APAP is considered first line over what other group?
NSAIDs as it has a better safety profile
When should we particularly use caution when using NSAIDs?
Low CrCl
Gastropathy
CV disease
Intravascularly depleted states (CHF)
If NSAIDs are used, how should they be used?
Short term, at low doses
Which type of NSAIDs have improved GI safety over others?
Nonacetylated
What is an alternative to oral agents of NSAIDs?
Topical
No long term studies
Potentially less effective than oral agents
What type of NSAID should be used if that patient has gastropathy?
COX II inhibitor - but should be used with caution in patients with CV risks
If a long term NSAID therapy is chosen, what do we give with it?
Gastroprotective agents (H2RAs, PPIs)
What may be necessary for chronic, severe pain in elderly adults?
Opioids
What are the pros of APAP in pain therapy?
Effective for mild-moderate pain Cheap Readily available Antidote available Limited DDIs
What are the cons of APAP therapy?
Potential for confusion with combination products and OTC, liver consideration
What is the max dose of APAP?
4g daily
How do we reduce APAP in hepatic insufficiency?
50-75%
What are the pros for NSAID therapy?
Effective - especially for mild-moderate pain associated with inflammation
Cheap
Availability of topical agents which can limited ADRs
What are the cons for NSAID therapy?
Renal insufficiency GI bleed CV events Edema Elevated BP Avoid in CKD and CHF Avoid chronic use
If a patient is taking ASA and wants to being an NSAID, what should be considered?
Adding H2RA/PPI
What can be added to celecoxib therapy for CV protection?
ASA
What is the preferred NSAID if the patient has a h/o GI bleed/ulcer?
Celecoxib
What is the preferred NSAID overall?
Salsalate
What is the non-preferred NSAID?
Diclofenac - may have the highest risk of CV effects
What NSAIDs are avoided in pain management in the elderly?
Indomethacin
Ketorolac
What are the pros of using opioids in pain of the elderly?
Effective for moderate to severe pain of various types
Multiple options for ROA
May be preferred over NSAIDs in stepwise therapy
What are the cons of opioids in pain of the elderly?
Constipation Respiratory depression Sedation Elderly more sensitive to effects Risk of falls increased Consideration of organ function (morphine: hepatic for metabolism, renal elimination; meperidine: renal for toxicity) Risk for allergies Potential for addiction Development of tolerance to effects of time
How should opioids be given in elderly with cognitive impairment?
Fixed/schedules dosing
Who should be in charge of dosing and conversions of methadone and fentanyl?
Those familiar with pharmacology - may take longer for elderly to reach ss
What are secondary amine TCAs?
Desipramine
Nortiptyline
What are tertiary amine TCAs?
Amitriptyline
Doxepin
Imipramine
What are the pros for TCA use for pain in the elderly?
Effective agents for depression & sleep
Can be used for other indications (HA)
Indicated for neuropathic pain
What are the cons for TCA use for pain in the elderly?
Anticholinergic effect Sedating Orthostasis Caution in CV disease Increased risk of falls
How do we dose TCAs?
Cautiously, unlikely to go to max doses
What are the preferred TCAs?
Secondary amines
Which TCAs should be avoided?
Tertiaty - higher risk for potent anticholinergic properties, sedating, and potential for orthostatic hypotension
What are the pros of SNRIs in pain for the elderly?
May be beneficial for neuropathic pain
Can also help with hot flashes
What are the cons of SNRIs in pain for the elderly?
May increase BP May affect cognition Cause dizziness Increased risk of falls DDI (duloxetine) Increases in HR (venlefaxine) Caution in renal insufficiency and dose adjust if CrCl < 30 (milnacipran)
What is the non preferred agent of SNRIs?
Milnacipran - cost, ADEs (nausea, constipation, hot flashes, hyperhidrosis, palpitations, dry mouth, HTN)
Avoid in narrow angle glaucoma
What are the SNRIs?
Duloxetine
Venlefaxine
Desvenlafaxine
Milnacipran
What are the pros of anticonvulsants?
Can be helpful for neuropathic and fibromyalgia
What are cons of anticonvulsants?
Sedation Ataxia Edema Carful dose titration Consideration of renal function with dosing - several dose adjustments (may not be ideal for fluctuating renal function)
What is the non-preferred anticonvulsant?
Carbamepine Monitor drug level Auto inducer Several DDIs Serum lab monitoring
What labs are monitored with carbamazepine?
CBC LFTs Cr BUN Electrolytes
What are the pros of corticosteroids?
Inflammation related pain (often gout, immune disorders - RA, etc) Cancer related bone pain Infiltration related pain Compression of nerves HA d/t intracranial pressure
What are the cons of corticosteroids?
Lots of AEs
Adrenal insufficiency - requires tapering off
ADEs limit use to last line typically
Try to use lowest effective dose for short amounts of time
What are corticosteroids AEs?
Glucose elevation Edema Increased BP Leukocytosis Bone demineralization Fat redistribution Psychosis/delirium in elderly
What are the pros of muscle relaxants?
Slight potential for efficacy in musculoskeletal pain - risks outweigh benefits
What are the cons of muscle relaxants?
ADEs similar to TCAs
Often ineffective
Concerns for abuse (carisprodol)
May relieve muscle pain but not by relaxing muscles
In true muscle spasms, BZDs or baclofen are better options
Increased risk of falls
What are the pros of BZDs?
Muscle spasms
Pain related anxiety
Low doses, short term or end of life
What are the cons of BZDs?
Elderly have increased sensitivity Cognitive impairment Delirium Falls Fractures MVAs
What are the pros of calcitonin/bisphosphonates?
Bone pain (metasteses)
Potentially second line for neuropathic conditions
Postosteoporotic fracture pain (calcitonin)
Great in those with OP
What are the cons of calcitonin/bisphosphonates?
Calcitonin (nausea, calcium/phosphate abnormalities)
Complicated administration
What are issues with taking bisphosphonates?
Attention to renal function
Must be able to sit upright, cost, ONJ, nausea, calcium abnormalities
What are the topical analgesics?
Lidocaine
Capsaicin
NSAIDs
What are the pros of topical analgesics?
Local effects
Lidocaine - neuropathic pain, ease of use, low risk of toxicity, no DDIs
Capsaicin - neuropathic pain
NSAIDs - some efficacy, systemic absorption minimal at recommended doses
What are cons of topical analgesics?
Skin irritation (esp w/capsaicin) Confusion with Lidoderm dosing potential problems Lidoderm CI in liver failure Capsaicin - burning
Should treatment be withheld out of fear of addiction or AEs?
No
How should dosing be considered in pain?
Initiated at low doses, titrated carefully, and monitored closely, but not withheld
What medications are elderly patients sensitive to for pain?
Opioid analgesics
What route of administration is preferred?
Oral - ease of dosing and predictable PK parameters
Why is IV therapy not preferred in elderly patients?
Rapid with a short half-life, but labor and cost intensive
Why are SQ and IM not preferred in elderly patients?
Wide fluctuations in absorption and do not last as long as oral medications
What route may be useful in patients with swallowing difficulties?
TD
Rectal
Transmucosal
What kind of regimen is recommended for chronic pain with cognitive impairment?
Scheduled
What type of medications should be used for breakthrough pain?
Short acting medications
What is the goal of pain therapy?
Acceptable QOL
Unrealistic to completely eliminate pain
