Pain Flashcards
What is Nociceptive pain?
Pain which results from injury to internal organs.
What is the difference between visceral and somatic pain?
Visceral pain is pain from internal organs
Somatic rain is pain referring to musculoskeletal pain
Which 2 types of pain are considered Neuropathic pain?
Fibromyalgia
Diabetic neuropathy
WRT the Pain Scale, what is considered Severe pain?
7 - 10
WRT the Pain Scale, what is considered Moderate pain?
4 - 6
WRT the Pain Scale, what is considered Mild pain?
1 - 3
Which drug classes should be used for Mild, Moderate , and Severe pain?
Mild: Non - Opioid ± adjuvant
Moderate - Severe: Opioid ± non-opioid or adjuvant
What is Acetaminophen’s MOA and its main effects?
MOA: (not fully known) Inhibition of PG syntheses
- Reduces pain
- Reduces Fever (its and antipyretic)
No anti-inflammation effects
What is the max dose for Acetaminophen?
4,000 mg/day
Acetaminophen BBW
Hepatotoxicity
Acetaminophen ADE
Severe skin rash (very rare): SJS, TEN
What is the dose of Acetaminophen for pediatrics (<12 years old)?
10 - 15 mg/kg/dose PO q4 - 6 hrs.
max 75 mg/kg/day
What is the reversal agent for Acetaminophen?
N-acetylcysteine
NSAIDS MOA
COX-1 and COX-2 inhibitor :
COX-1 and COX-2 are catalyst which convert arachidonic acid to PG and Thromboxane A2. Therefore all NSAIDS decrease formation of PG and decrease inflammation, pain and fever.
What is the benefit of selective COX-2 inhibitors?
Decreases GI risk
Which agent is a irreversible COX-1 inhibitor?
Aspirin
Which agents are Non-Selective COX-1 and COX-2 inhibitor NSAIDS?
- Ibuprofen
- Indomethacin
- Naproxen
- Ketorolac
Which agents are Selective COX-2 inhibitor NSAIDS?
- Celecoxib
- Diclofenac
Some COX-2 selectivity:
- Meloxicam
- Nabumetone
NSAIDS boxed warnings
GI risk (bleeding and ulceration)
CV risk (except for aspirin): can cause MI and Stroke
Coronary Artery Bypass Graft (CABG) surgery: NSAIDS are contraindicated, Aspirin is recommended
Premature closure of the ductus arteriosus: contraindicated in 3rd trimester of presence (>30 weeks)
NSAIDS ADE
Overuse can cause renal failure
Increase BP (contraindicated in uncontrolled HTN)
Premature closure of the ductus arteriosus: contraindicated in 3rd trimester of presence (>30 weeks)
What is the dose of Ibuprofen for pediatrics?
5 - 10 mg/kg/dose PO q6 - 8 hrs
max 40mg/kg/day
Which NSAIDS should be avoided in psych patients b/c it has a high risk for CNS side effects/
Indomethacin
Which NSAIDS is dosed BID?
Naproxen
What is the max day supply of Ketorolac?
5 days
not just for PO but for all dosage forms in combination
Ketotolac warning
Can cause:
- Bleeding
- Acute renal failure
- Liver failure
Do Selective or Non-Selective NSAIDS have a higher CV risk?
Selective
Do Selective or Non-Selective NSAIDS have a higher GI risk?
Non-Selective
Which NSAIDS has a Sulfonamide allergy attached to it?
Celecoxib
Which NSAIDS has the highest COX-2 selectivity?
Celecoxib
Which NSAIDS combo drug should be avoided in women of childbearing potential unless capable of comply with effective BC measures?
Diclofenac + Misoprostol = Arthrotec
Indication: RA, Osteoarthritis
Salicylate NSAIDS BBW
Avoid using in children and teenagers with any viral infection due to risk of Reye’s syndrome
Salicylate ADE
Dyspepsia
Heartburn
Bleeding
Important drug-drug interactions with NSAIDS
- Take aspirin 1 hour before or 8 hours after ibuprofen
- NSAIDS can increase Lithium and Methotrexate levels
Opioid MOA
mu receptor agonists in the CNS
True or False: REMS program exists for all opioid medications
True
What schedule is Codine?
C-II
C-III when in combination with other meds
Codine contraindications
< 12 years of age
< 18 years of age for treatment of tonsillectomy/adenoidectomy surgery, can cause death
Codine AED
Constipation
Fentanyl sig
Apply 1 patch q72hrs.
Fentanyl contraindications
Not to be used in opioid-naive patients
Only for patient who have been using morphine 60mg/day or equivalent for at least 7 days
How should you dispose a Fentanyl patch
In the toilet
Which Opioid have d-d interactions with CYP3A4 inhibitors?
CYP3A4 inhibitors can cause fatal overdose
- Hydrocodone
- Fentanyl
- Methadone
- Oxycodone
Which Opioid has a BBW for QT prolongation and senior arrhythmias?
Methadone (Dolophine)
What are the steps to dose conversion between an Opioid agents?
- Calculate total 24 hours dose requirement for current drug
- Use ratio-conversion to calculate dose of new drug
- Calculate 24 hours dose of new drug and reduce dose at least by 25%
- Divide to attain appropriate interval or new drug
- BTP 5 - 17% of daily dose
True or False: Complaints of itching or rash are true allergies for Opioids.
False
not true allergy
True allergy reactions are:
- Difficulty breathing
- Severe drop in BP
- Serious rash
- Swelling of face, lips, tongue or larynx
What are the 3 Opioid drug classes we can switch between in case of true opioid allergy?
- Cod- : Codeine, Hydrocodone, Oxycodone
- Morph- : Morphine, Hydromorphone, Oxymorphone
- Norph- : Buprenorphine
Opioid ADE
Constipations (will never improve)
What drugs can be used to treat Opioid induced constipation? Class? Warning?
Class: PAMORAs
- Methylnatrexone (Relistor)
- Naloxegol (Movantik)
Both have warning of GI perforation
What schedule is Tramadol?
C-IV
Tramadol and Tapentadol MOA
mu-opioid receptor agonists
norepinephrine re-uptake inhibitors
serotonin re-uptake inhibitor (only tramadol)
Tramadol and Tapentadol warning
Siezure risk
What schedule is Tapentadol?
C-II
What is considered a large dose of Opioid?
≥ 50mg of morphine or equivalent dose
Buprenorphine MOA and Indication
MOA: Partial mu-opioid agonist
Indication: @ low dose for pain, @ high dose for addiction by suppressing withdrawal symptoms
Naltrexone indication
Alcohol and opioid dependence
Narcan SIG and Dose?
Nasal spray: 4 mg administered in 1 nostril
IV/IM/SC: 0.4 - 2 mg q2-3 min or IV infusion at 0.4 mg/hr
What schedule is Buprenorphine?
C-III
Gabapentin ADE
- Somnolence
- Ataxia
- Peripheral edema
- Weight gain
What schedule is Lyrica?
C-V
What is the max dose for Gabapentin?
3,600mg/day
What is the max dose for Lyrica?
450mg/day
Lyrica approved indications?
Fibromyalgia
PHN (Postherpetic Neuralgia)
Neuropatic pain
What is the only FDA approved drug for the treatment of triennial neuralgia?
Carbamenzepine
Name the 3 agents in the class for antispasmodics with analgesic effects
Baclofen (can cause sedation, dizziness, confusion)
Cyclobenzaprine (can cause dry mouth)
Tizanidine (can cause hypotension, dry mouth, weakness, QT prolongation)
Name the 2 agents in the class for antispasmodics without analgesic effects
Carisoprodol
Methocarbamol
What schedule is Carisoprodol in?
C-IV
Which SNRI and TCA can be used to treat neuropathic pain?
Duloxetine
Amitriptyline
How long can Lidocaine patch be applied for?
What is the number of max patch at once?
12 hours/day
Max of 3 patchs a a time
Generic for
Bengay
Aspercreme
Bengay: Methyl sailcylate
Aspercremem: Trolamine
True or False: Lidocaine patch may be cut.
True
What is the MDD for Ibuprofen?
3.2 grams/day
