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pain, migraine, gout 372 > Pain > Flashcards

Pain Flashcards

1
Q

Types of pain (2 categories)

A

Nociceptive

Pathophysiologic

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2
Q

What is nociceptive pain?

A

Pain that occurs when sensory nerves (nociceptors) identify tissue damage because injured tissue (visceral-organ, skin, muscle, joint, bone, etc) releases

PGs
substance P
histamine
and other substances

which stimulate nocireceptors to send impulses to the brain signaling pain=feeling pain

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3
Q

What is pathophysiologic pain

A

Pain due to damage or malfunctioning of the nervous system.

AKA neuropathic pain

Includes: fibromyalgia, diabetic neuropathy, chronic headaches, drug induced toxicities, and others

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4
Q

Acute vs chronic pain

A

Acute pain is typically nociceptive, and the pain typically goes away when the cause has been resolved

Chronic pain persists beyond normal healing time (usually 3 months) and sometimes without acute/visible injury (eg. OA, crushed lumbar, diabetic neuropathy, etc)

Chronic pain is divided into:
cancer pain
non-cancer pain

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5
Q

Treating pain

A

Pain is subjective-pain scales are useful to assess pain severity

Mild 0-3:
non-opioid
+/- adjuvant

Moderate 4-6
opioid for mild-moderate
+/- non-opioid
+/- adjuvant

Severe 7-10
opioid for moderate-severe
+/- non-opioid
+/- adjuvant

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6
Q

non-opioid analgesics

A

acetaminophen

NSAIDs

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7
Q

Adjuvants for pain management

A

Commonly used for neuropathic pain

  1. anti-epileptic drugs (gabapentin, pregabalin, carbamazepine)
  2. analgesic antispasmodics (Backofen, cyclobenzaprine, tizanidine)
  3. sedating antispasmodics (carisoprodol, methocarbamol)
  4. SNRIs and TCAs (milnacipran, amitriptyline, desipramine, duloxetine)
  5. topicals (lidocaine, capsaicin, methyl salicylate)
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8
Q

ACetaminophen MOA

A

Reduces pain and fever BUT is NOT anti-inflammatory

MOA not well defined but is thought to inhibit PG synthesis

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9
Q

Name agents for mild pain (rx and OTC)?

A

Acetaminophen (Tylenol, Ofirmev, FeverALL)

+ Hydrocodone (Vicodin, Norco, Lortab)

+ Oxycodone (Percocet, Endocet, Primlev)

+ codeine (Tylenol #2, 3, 4)

+ tramadol (Ultracet)

+butalbital/Caffiene (Fioricet)

+benadryl (Tylenol PM)

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10
Q

Brand name of Acetaminophen?

A

Tylenol, Ofirmev, FeverALL

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11
Q

Brand name of Acetaminophen + Hydrocodone?

A

Vicodin

Norco

Lortab

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12
Q

Brand name of Acetaminophen + Oxycodone?

A

Percocet

Endocet

Primlev

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13
Q

Brand name of Acetaminophen + Codeine?

A

Tylenol #2, 3, 4

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14
Q

Brand name of Acetaminophen + Tramadol?

A

Ultracet

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15
Q

What’s the max daily dose of Acetaminophen in adults?

A

Box: Keep below 4,000 mg/day (4g/day)

To prevent hepatoxicity

Doses >2g/day can increase INR in warfarin patients

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16
Q

Children’s dosing of Acetaminophen? Max daily dose?

A

10-15 mg/kg Q4-6H

Max 5 doses/day

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17
Q

What’s the conc of Acetaminophen in infants and children’s suspension?

A

160mg/5mL

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18
Q

SEs of Acetaminophen use?

A

Hepatoxicity (with overdose), SJS/TEN, nephrotoxic-rare but seen in chronic overdose (safer than NSAIDs)

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19
Q

What’s the DOC in pregnancy for pain?

A

Acetaminophen

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20
Q

Antidote for Acetaminophen overdose?

A

N-acetylcysteine (NAC, Mucomyst, Cetylev, Acetadote)

comes oral and IV

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21
Q

Moa of N-acetylcysteine (Antidote for Acetaminophen overdose)?

A

Restores intracellular glutathione (acts as a glutathione substitute)

Rumack-Matthew nomogram uses serum acetaminophen level vs time since ingestion to determine if hepatotoxicity is likely and the need for NAC

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22
Q

MOA of Aspirin and other NSAIDs (not acetaminophen)?

A

Aspirin - irreversibly blocks COX 1=decrease TxA2 (which is required for platelet activation & aggregation)

Other NSAIDs - reversibly block cox 1 &2 (non-selective) or COX-2 only (selective)

COX1 protects the gastric mucosa so selective (only cox2) NSAIDs decrease GI risk

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23
Q

While cox-2 selective agents have lower GI bleeding risk, but what risk increases with their use?

A

Cardiovascular risk- MI and stroke

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24
Q

List NSAIDs, Salicylates agents

A

Aspirin (Acetylsalicylic acid) - Bayer, Ascriptin, Bufferin, Ecotrin, Durlaza

Non-Acetylated Salicylates:

Salsalate

Mg Salicylate (Doans)

Choline Mg Trisalicylate

Diflunisal

Salicylate salts

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25
Q

Risk that increases with NSAIDs use. Groups with highest risk?

A

GI bleeding

Elderly
Hx of GI bleed
Taking systemic steroids
On SSRIs or SNRIs

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26
Q

NSAID SE (all NSAIDs)

A
  1. decrease renal clearance-ALL should be used cautiously or avoided in renal failure
  2. increase blood pressure-caution in controlled HTN, avoid in uncontrolled HTN
  3. premature closure of ductus arteriosus=HF in baby-Don’t use in 3rd trimester of pregnancy
  4. nausea-salicylates are worse than other NSAIDs. To minimize, take w/ food, enteric coated, or buffered products
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27
Q

Salicylate SEs?

A 
Avoid with NSAID hypersensitivity, nasal polyps, asthma
Avoid in children/teens -Reye's
SJS/TEN
Increases bleeding risk
GI ulceration & bleeding can occur
Dyspepsia
Heartburn 
Bleeding
Nausea
BP may increase (monitor)
CNS effects
Photosensitivity
Edema
Hyperkalemia
Blurred Vision

OVERDOSE: tinnitus

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28
Q

List agents under NSAIDs, others

A

Ibuprofen (Motrin, Advil)

Naproxen Na

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29
Q

Brand name of Ibuprofen (NSAIDs, others)?

A

Motrin

Advil

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30
Q

Brand name of Naproxen-Esomeprazole?

A

Vimovo

PPI used to protect gut from damage caused by NSAID

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31
Q

How are all forms of Naproxen dosed?

A

All given BID

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32
Q

Advantage of Naproxen formulations?

A

Relatively lower cardiac risk

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33
Q

Agents under non-selective NSAIDs?

A

IN SKIP- block Cox1 and Cox2
GI risk, CV risk, Post CABG risk

Ibuprofen (Motrin, Advil, Caldolor, NeoProfen)
Naproxen (Aleve, Naprelan, Naprosyn)

Sulindac
Ketorolac (Toradol, Sprix)
Indomethacin (Indocin, Tivorbex)
Piroxicam (Feldene)

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34
Q

Brand name of Diclofenac?

A

Box-Avoid in women of child bearing potential

Voltaren
Cambia
Cataflam
Enova
many others

+misoprostol (Arthrotec)
misoprostol is used to replace gut protective PG to decrease GI risk. CAN cause uterine contarctions-abort pregnancy. Also causes cramping & diarrhea

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35
Q

Brand name of Indomethacin

A

Indocin
Tivorbex

High risk for CNS side effects- avoid in psych pts

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36
Q

Brand name of Piroxicam

A

Feldene

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37
Q

Brand name of Ketorolac

A

Toradol

Sprix NS

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38
Q

SEs unique to indomethacin (Indocin)?

A

High risk for CNS SEs (avoid in psych conditions)

GI toxicity

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39
Q

SEs unique to Piroxicam (Feldene)?

A

High risk for GI toxicity and severe skin rxns (including SJS/TEN)

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40
Q

SEs unique to Ketotolac (Toradol)?

A

Increase bleeding

Acute renal failure

Liver failure

Anaphylactic shock

Box-only for short term mod-severe pain as continuation of IV or IM Tx (MAX COMBINED duration IV+IM+PO+Nasal 5 DAYS) NOT for intrathecal or epidural use

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41
Q

Max duration of Ketorolac (Toradol) use?

A

Max 5 days in adults of all combined delivery methods (IV, IM, PO, nasal)

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42
Q

COX-2 selective agents?

A 
Celecoxib (Celebrex)
Diclofenac (Volateren)
Meloxicam (Mobic)
Etodolac (Lodine)
Nabumetone (Relafen)
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43
Q

Brand name of Celecoxib (COX-2 selective agents)?

A

Celebrex

highest cox 2 selectivity

Contraindicated in sulfa allergy

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44
Q

Brand name of Meloxicam (COX-2 selective agents)?

A

Mobic

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45
Q

Brand name of Etodolac (COX-2 selective agents)?

A

Lodine

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46
Q

Brand name of Nabumetone (COX-2 selective agents)?

A

Relafen

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47
Q

Which COX-2 selective agent has highest COX-2 selectivity and is CI with Sulfonamide allergy?

A

Celecoxib (Celebrex)

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48
Q

How do u mitigate upset stomach from NSAID use?

A

Take with food or use enteric coated or buffered forms

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49
Q

Which meds shouldn’t NSAIDs be used with?

A

Multiple NSAIDs shouldn’t be used together. If taking aspirin + NSAID take aspirin 1 hr before OR 8 hours after

NSAIDs increase levels of lithium and methotrexate

Steroids
Anticoagulant

Antidepressant, including 
Fluoxetine
Paroxetine
Sertraline
Citalopram
Venlafaxine
Others
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50
Q

When should NSAIDs be avoided?

A

If you’ve experienced breathing problems or allergic-type rxns after taking aspirin or other NSAIDs

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51
Q

Effect of NSAIDs on BP?

A

NSAIDs can raise BP

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52
Q

NSAIDs and photosensitivity?

A

Limit sun exposure; use broad spectrum sunscreen (blocks both UVA and UVB)

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53
Q

Which opioids are classified as pure opioid receptor agonists?

A

Codeine

Fentanyl

Hydrocodone

Hydromorphone

Methadone

Morphine

Oxycodone

Oxymorphone

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54
Q

What’s the primary receptor for pain relief?

A

Mu opioid receptor

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55
Q

While full agonists don’t have a true ceiling effect, how should high doses be used!

A

Rotated with other opioids to reduce risk of tolerance

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56
Q

Brand name of morphine (long-acting brands)?

A

MS Contin

Kadian

MorphaBond

Duramorph

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57
Q

How should long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol) be used?

A

Don’t crush or chew any of these

58
Q

Avinza and alcohol use?

A

No alcohol - can shorten long-acting duration

Can sprinkle on applesauce, soft food (Kadian too)

59
Q

SEs of long-acting morphine (MS Contin; Avinza; Kadian; Oramorph SR; Roxanol)?

A

Constipation

N/V

60
Q

Tolerance develops to all SEs except?

A

Constipation

61
Q

What’s used for constipation from opioids?

A

Stimulant laxatives (senna, bisacodyl)

Osmotic laxatives (MOM)

Methylnaltrexone (Relistor) - last line

62
Q

Brand name of Fentanyl patch?

A

Duragesic

63
Q

Brand name of Fentanyl pills?

A

Abstral

Fentora SL

64
Q

How’s Duragesic (fentanyl patch) used?

A

12 (delivers 12.5 mcg/hr), 25, 50, 75, 100 mcg/hr

Change transdermal patch Q3 days

65
Q

If pain is controlled, but short-lived with Duragesic (Fentanyl patch), how should they be treated? (As u would do with any long-acting opioid)?

A

Don’t increase dose, reduce freq

From Q72h => Q48h

66
Q

Role of Fentanyl, in any form, in therapy?

A

Chronic pain management only

67
Q

How do adjust oral opioid when starting fentanyl?

A

Reduce dose by 50% at first of oral opioid

68
Q

Which form of fentanyl is a REMS drug?

A

Onsolis

69
Q

How do u dispose of Duragesic (fentanyl patch)?

A

Dispose in toilet

Or

Cut up and put in coffee grounds

70
Q

Brand name of Hydromorphone?

A

Dilaudid

71
Q

Brand name of Oxycodone CR?

A

OxyContin

OxyContin OP

72
Q

Brand name of Oxycodone + Acetaminophen?

A

Endocet

Percocet

Roxicet

73
Q

BBWs of Oxycodone (OxyContin; OP - CR Oxycodone) +

Oxycodone + Acetaminophen (Percocet, Endocet, Roxicet)?

A

Report abuse

Avoid with 3A4 inhibitors (eg Amiodarone, Fluconazole, Grapefruit, Verapamil etc)

74
Q

Brand name of Oxymorphone?

A

Opana

Opana ER

75
Q

What’s unique about use of Oxymorphone (Opana; Opana ER)?

A

Take on empty stomach (most others are use with food to avoid stomach upset)

No alcohol with Opana ER

76
Q

Brand name of Methadone?

A

Dolophine

Methadose - liquid

77
Q

Concern with using Methadone (Dolophine, Methadose) and Meperidine (Demerol)?

A

Serotonergic, when used in combo with other drugs

78
Q

Brand name of Meperidine?

A

Demerol

79
Q

Role of Meperidine (Demerol) in therapy?

A

Short duration so action (pain control for max 3 hrs)

Avoid as agent for chronic pain management

80
Q

Brand name of Hydrocodone + Acetaminophen?

A

Lorcet

Lortab

Vicodin

Norco

81
Q

Brand name of Hydrocodone + Acetaminophen - referred to as safer combo?

A

Norco (325mg APAP)

82
Q

What’s concern with Hydrocodone + Acetaminophen (Lorcet, Lortab, Vicodin, Norco)?

A

Watch for APAP max dosing (combo with APAP higher than 325mg is been phased out)

83
Q

Brand name of Codeine + Acetaminophen?

A

Tylenol #2, 3, 4

84
Q

List combination opioid agonists/norepinephrine uptake inhibitors and Tramadol also inhibits 5 Reuptake

A

Tramadol (Ultram, Ultram ER, Conzip IR/ER)

Tramadol + Acetaminophen (Ultracet)

Tapentadol (Nucynta, Nucynta ER)

85
Q

Brand name of Tramadol + Acetaminophen?

A

Ultracet

86
Q

Brand name of Tramadol?

A

Ultram

Ultram ER

Conzip IR/ER

87
Q

Brand name of Tapentadol?

A

Nucynta

Nucynta ER

88
Q

Whats warning associated with Tramadol use?

A

Increased seizure risk (serotonin syndrome)

89
Q

SEs of Tapentadol (Nucynta, Nucynta ER)?

A

Dizziness

Drowsiness

Nausea

But lower GI than stronger opioids

90
Q

What should be avoided with Tapentadol (Nucynta, Nucynta ER)?

A

No alcohol

91
Q

All opioids have a no alcohol use warning, but which ones have a special warning to avoid alcohol use?

A

Opana ER (Oxymorphone ER)

Nucynta ER (Tapentadol ER)

Avinza

92
Q

Which opioid has a take on empty stomach direction (almost all others are use with food)?

A

Opana (Oxymorphone)

93
Q

Morphine and renal insufficiency?

A

If switching to morphine and pt has renal insufficiency, reduce dose by 50% of TDD

(Morphine has an active metabolite that’s renally cleared)

94
Q

When converting from 1 opioid to another, what should always be considered?

A

Always Use breakthrough med, as-needed, when converting

95
Q

Converting to Fentanyl patch?

A

Find TDD in mg

Convert to mcg (multiple by 1,000)

Divide by 24 (to get patch dose)

Fentanyl is dosed mcg/hr

96
Q

When converting 1 opioid to another, do u round up?

A

No! Never!

Round down (use breakthrough doses for compensation)

97
Q

What changes do u make if medicine works well to control pain, but runs out too fast?

A

Shorten dosing interval (don’t increase dose, this will cause a risk of respiratory depression)

98
Q

How to convert from 1 opioid to another?

A

Calculate total 24h dose req of current drug

Use ratio-conversion to calc dose of new drug (make sure numerators & denominators match in both drug & route of admin)

Calculate 24h dose of new drug & reduce dose at least 25% (Note: if problem on exam says to find equivalent dose, the don’t reduce it)

Divide to attain appropriate interval and dose for new drug

Always have breakthrough pain (BTP) med available while making changes (BTP dose ranges from 5-17% of total daily baseline opioid dose)

99
Q

Role of Naloxone (as a single agent) in therapy?

A

Used for Opioid overdose

100
Q

Whys repeat dosing of Naloxone required?

A

Opioid may last longer than blocking agent

101
Q

Effect of Naloxone in pts physically dependent on opioids?

A

Will cause acute withdrawal syndrome (pain, anxiety, tachypnea)

102
Q

Acute overdose s/sx to watch out for when using Naloxone?

A

Somnolence

Respiratory depression with shallow breathing

Cold and clammy skin

Constricted (pinpoint, miosis) pupils

Can lead to coma and death

103
Q

What’s the role of Suboxone (Buprenorphine + Naloxone) in therapy?

A

Used as alternative for methadone (so pts can get from regular doctor and filled at any pharmacy and can get over opioids since withdrawal sx are reduced)

Used daily for addiction

104
Q

SEs of Buprenorphine + Naloxone (Suboxone)?

A

Sedation

105
Q

Buprenorphine and QT interval?

A

Prolongs QT interval (avoid in pts at risk of arrhythmia)

106
Q

List Antispasmodics with analgesic effects

A

Baclofen (Lioresal)

Cyclobenzaprine (Flexmid)

Tizanidine (Zanaflex)

107
Q

Brand name of Baclofen (Antispasmodics with analgesic effects)?

A

Lioresal

108
Q

Brand name of Cyclobenzaprine (Antispasmodics with analgesic effects)?

A

Flexmid

109
Q

Brand name of Tizanide (Antispasmodics with analgesic effects)?

A

Zanaflex

110
Q

SEs of all skeletal muscle relaxants?

A

Excessive sedation, dizziness, confusion

111
Q

SEs of Cyclobenzaprine (Flexmid)?

A

Xerostomia (may have efficacy with fibromyalgia)

112
Q

SEs of Tizanidine (Zanaflex)?

A

Central alpha-1-agonist => Hypotension, dizziness, xerostomia,
weakness

113
Q

List drugs that exert their effects by sedation

A

Carisoprodol (Soma)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin, Robaxin-750)

114
Q

Brand name of Carisoprodol (drugs that exert effects by sedation)?

A

Soma

C IV (due to dependence, withdrawal sx and diversion and abuse)

115
Q

Brand name of Metaxalone (drugs that exert effects by sedation)?

A

Skelaxin

116
Q

Poor CYP 2C19 metabolizes and Carisoprodol (Soma)?

A

Poor CYP 2C19 metabolizes will have higher Carisoprodol (Soma) conc (up to 4-fold)

117
Q

What meds is Tizanidine (Zanaflex) CI with?

A

Ciprofloxacin & Fluvoxamine (due to elevated Tizanidine levels)

118
Q

List common neuropathic pain agents

A

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

Gabapentin (Neurontin)

Amitriptyline (Elavil)

119
Q

Brand name of Pregabalin (Neuropathic pain agents)?

A

Lyrica

120
Q

Brand name of Duloxetine (Neuropathic pain agents)?

A

Cymbalta

121
Q

Brand name of Gabapentin (Neuropathic pain agents)?

A

Neurontin

122
Q

Brand name of Amitriptyline (Neuropathic pain agents)?

A

Elavil

123
Q

SEs of Pregabalin (Lyrica) and Gabapentin (Neurontin)?

A

Dizziness

Somnolence

Peripheral edema

Weight gain

Ataxia

Diplopia

Blurred vision

Xerostomia

Mild euphoria

124
Q

SE of Amitriptyline (Elavil) - mostly uncommon with low doses used for neuropathic pain

A

Anticholinergic

125
Q

List Fibromyalgia agents

A

Milnacipran (Savella)

Pregabalin (Lyrica)

Duloxetine (Cymbalta)

126
Q

Brand name of Milnacipran (Fibromyalgia agent)?

A

Savella

127
Q

SEs of Milnacipran (Savella)?

A

Nausea

HA

Constipation

Dizziness

Insomnia

Hot flashes

128
Q

Topical pain agents, for localized pain

A

Lidocaine 5% patches (Lidoderm)

Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)

Diclofenac topical (Voltaren gel, Flector patch)

Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)

129
Q

Brand name of Lidocaine 5% patch?

A

Lidoderm

130
Q

Brand name of Capsaicin 0.025% and 0.075%?

A

Zostrix

Zostrix HP

131
Q

What’s Lidoderm (Lidocaine 5% patch) approved for?

A

Postherpetic neuralgia (shingles)

132
Q

Can Lidoderm (Lidocaine 5% patch) be cut into smaller pieces?

A

Yes! B4 removing backing

133
Q

Max number of Lidoderm (Lidocaine 5% patch) that can be applied at one time? Duration of applied patch use?

A

Max of 3 Lidoderm (Lidocaine 5% patch) at one time

12 hrs on and 12 hrs off

134
Q

SEs of Methyl salicylate topical OTCs (BenGay, Icy Hot, Precise, SalonPas etc)?

A

May cause 1st to 3rd degree burns (mostly in patients with neuropathic damage)

135
Q

How do u obtain best results on Capsaicin 0.025% and 0.075% (Zostrix, Zostrix HP)?

A

Best results typically occur after 2 to 4 wks of continuous use

Don’t use PRN, since freq, long-term use is required for benefit

136
Q

SEs of Ibuprofen?

A

May cause acute kidney problems

May cause increase in BP (codeine and APAP doesn’t cause BP rise)

137
Q

T/F? It’s preferable to treat severe pain at initial onset?

A

T

138
Q

Best NSAID for renal pts or lithium users

A

Sulindac

139
Q

Ibuprofen Adult dosing

A

OTC
200-400 mg Q4-6H
MAX: 1.2g/day

RX
400-800 mg Q6-8H
Max 3.2g/day

140
Q

Pediatric Ibuprofen dosing

A

5-10mg/kg/dose Q6-8H

Max: 40mg/kg/day

pain, migraine, gout 372 (6 decks)

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