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NMSP > Pain Drugs > Flashcards

Pain Drugs Flashcards

1
Q

Pain Management Algorithm

A
  1. Non-pharmacologic therapy like exercising, PT, sleep hygiene, etc
  2. Nociceptive pain –> First line = NSAIDs (if active inflam)

or, Neuropathic pain and/or antiepileptic drugs –>
First line = antidepressants (tricyclics, SNRIs) or antiepiletics drugs (gabapentinoids - gabapentin or pregabalin, sodium channel agents - lidocaine, carbamazepine, oxcarbazepine)

  1. Second and third line = Acetaminophen, Topical agents (NSAIDs, lidocaine, capsaicin), Opioids, neuromodulation
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2
Q

What drug is this toxicity associated

Ergot alkaloids are contraindicated with potent inhibitors of CYP3A4 (includes protease inhibitors, azole antifungals, and some macrolide antibiotics);

concomitant use associated is with an increased risk of vasospasm leading to cerebral ischemia and/or ischemia of the extremities.

A

dihydroergotamine

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3
Q

What are ubrogepant and rimegepant?

A

Nothing bolded for these.

Calcitonin gene-related peptide receptor antagonist for tx of migraine.

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4
Q

Name of 2 drugs that are also antidepressants

A
  1. amitriptyline, other TCA

2. duloxetine, other SNRI

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5
Q

Name of 2 drugs that are NMDA antagonists

A
  1. ketamine

2. methadone

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6
Q

Name of 2 drugs that are adrenergic agonists

A
  1. dexmedetomidine

2. clonidine

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7
Q

What are some topical anti-pain agents?

A
  1. Capsaicin: stimulates TRPV1 receptors, desensitizes substance P, mod to poor efficacy for nociceptive and neuropathic pain.
  2. Camphor: Also desensitizes TRPV1 receptors
  3. Menthol: stimulates TRPM8 “cold” receptors to cause cool sensation
  4. Topical NSAIDs
  5. Topical Na+ channel blocker
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8
Q

Name of the 2 drugs that are AEDs used in neuropathic pain

A
  1. pregabalin

2. gabapentin

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9
Q

Name of the 3 drugs that are topical analgesics

A
  1. capsaicin, camphor
  2. menthol
  3. lidocaine
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10
Q

Name of the 3 drugs that are anti-migraine agents

A
  1. sumatriptan
  2. dihydroergotamine
  3. (lasmiditan, ubrogepant)
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11
Q

Definition of analgesic

A

drugs that relieve pain without causing LOC

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12
Q

What drug is an alpha2-adrenergic agonist

used for 1) hypertension and 2) relief of severe epidural pain

administered by continuous infusion through an epidural catheter

highly lipid soluble, escapes to blood to causes hypotension, confusion, dry mouth

A

Clonidine

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13
Q

What drug is a noncompetitive NMDA receptor antagonist that blocks glutamate.

Sub-anesthetic doses for analgesia, acute and chronic pain. Modulates central sensitization, hyperalgesia and opioid tolerance. Treats complex regional pain syndrome, neuropathic pain.

Causes cataleptic-like state with dissociation from surrounding environment.

A

ketamine

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14
Q

How is ketamine administered?

A

IV infusion

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15
Q

Algorithm for neuropathic pain

A

First line: Ca alpha 2 delta ligands (pregabalin, gabapentin) or SNRIs (duloxetine, venlafaxine) or TCAs (amitriptyline, nortriptyline)

Second line: Other anti-epileptics (valproic acid), opioids, or tramadol

Third line : NMDA antagonists (dextromethorpan), combo of analgesics, or Tizanidine Baclofen

Fourth line: Botulinum toxin injection or consider intrathecal ziconotide

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16
Q

What drug causes

(MOA) Decreased stimulation of the trigeminal system

& is used tx migraine pain without causing vasoconstriction

A

lasmiditan

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17
Q

What drug has these BLACK BOX WARNINGS

Risk of medication
errors/ingestion by children leads to
overdose and death (respiratory depression)

addiction, abuse, and misuse

interactions with drugs affecting cytochrome P450 isoenzymes

withdrawal syndrome

Increased risk of respiratory depression from concomitant use with benzodiazepines or other CNS depressants

A

Tramadol

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18
Q

What drug is used for

  1. Fibromyalgia
  2. Neuropathic pain associated with diabetic peripheral neuropathy
  3. Postherpetic neuralgia
  4. Seizures
A

Pregabalin

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19
Q

What types of drugs would you use for severe pain

A

non-opioid analgesics + opioids + adjuncts

adjuncts- called co-analgesics, include TCAs, SNRIs, anticonvulsants, topical anesthetics

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20
Q

What is gabapentin?

A

Gaba analog like pregabalin, less reliable pharmacokinetics and more sedating

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21
Q

What is the first-line therapy in nociceptive pain

A

NSAIDs, if an active inflammatory process is present

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22
Q

What is the black box warning for duloxetine?

A

Increased risk of suicidal thoughts and behaviors.

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23
Q

What is the first-line therapy in neuropathic pain

A

antidepressants and antiepileptic drugs

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24
Q

What do you give if neuropathic pain is persistent even after first-line therapy

A

Acetaminophen, Topical agents, Opioids (only when other modes have been used)

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25
Q

Which COX enzyme is induced and which COX enzyme is constituent

A

COX-1: constiuent

COX-2: induced

26
Q

What are the other selective 5-HT1B and 5-HT1D agonists, other than Sumatriptan?

A

multiple others: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, zolmitriptan… differences are primarily in pharmacokinetics and dosage forms

27
Q

What drug?

MOA: N-type voltage sensitive calcium channels located on the nociceptive afferent nerves of the dorsal horn

Intrathecal route, its a peptide

A

ziconotide

28
Q

What drug has this clinical application?

Management for severe chronic pain

(in patients requiring intrathecal therapy and who are intolerant or refractory to other therapies, eg:
• systemic analgesics
• adjunctive therapies
• intrathecal morphine)

A

ziconotide

29
Q

What drug has this BBW?

severe psychiatric symptoms and neurological impairment may occur

this medication is among those listed for heightened risk of causing significant patient harm when used in error

A

ziconotide

30
Q

What is an alpha-2-adrenergic agonist used analgesia and sedation? It is a potent anxiolytic, part of multimodal approach to postoperative pain management

A

Dexmedetomidine

31
Q

NOCICEPTIVE PAIN ALGORITHM

A

mild-mod pain:
topical agents –> acetaminophen/paracetamol (APAP)–> NSAIDs + PPI, or COX-2 inhibitors +/- APAP

mod- to severe pain:
if NSAID risk then use APAP
if no NSAID risk then use NSAIDs + PPI, or COX-2 inhibitors +/- APAP

IF the pain does not go…. then use TCAs (antidepressants, which are amitriptyline or duloxetine)

IF pain is still there, use opioids and add Baclofen or Tizanidine if spasms present

32
Q

Which COX enzyme plays a physiological role in the kidney

A

COX-2

33
Q

Which COX enzyme produces the most erythema, edema, and pain

A

COX-2

34
Q

What are the 3 main effects of aspirin

A

decreases prostaglandin and TXA2 ,
inhibits platelet aggregation,
has antipyretic, analgesic, and anti-inflammatory properties

35
Q

How many types of aspirin tablets are there?

A

2

immediate release and extended release capsule

36
Q

What drug has the following toxicities:

  1. ulcer
  2. inc. risk for bleeding
  3. multiple drug interactions
  4. inc. risk of Reye syndrome in kids under 18
  5. increase in serum Cr
A

aspirin

37
Q

Aspirin/Salicylate toxicity progresses to..

A

metabolic acidosis that becomes life-threatening

38
Q

What are the main functions of nonaspirin NSAIDs

A

suppress inflammation, pain, and fever like aspirin

39
Q

What drug has the risks of gastric ulcer, renal impairment, and bleeding like aspirin

A

nonaspirin NSAIDs

40
Q

what are the 2 main differences in nonaspirin NSAIDs and aspirin

A

Nonaspirin NSAIDs:

  1. are reversible, so effects decline as blood levels decline
  2. have inc. risk of MI and stroke

therefore use lowest effective dosage for shortest possible time

41
Q

what are the nonaspirin NSAIDs

A

ibuprofen, naproxen, coxibs

42
Q

which drug has this black box warning:

may cause fetal renal dysfunction leading to oligohydramnios, > 30 weeks closure of ductus arterious

inc. risk of MI and stroke, contraindicate in CABG
inc. risk of GI bleeding

A

ibuprofen

43
Q

which drug is similar to ibuprofen except that its half life is longer than ibuprofen

A

naproxen

44
Q

Which drug selectively blocks COX-2

A

celecoxib (Celebrex)

45
Q

which drug DOES NOT inhibit platelet aggregation, so does not have risk of bleeding

A

celecoxib

46
Q

what is the off-label use of celecoxib

A

gout

47
Q

which drug has the following black box warning:

may cause fetal renal dysfunction leading to oligohydramnios, > 30 weeks closure of ductus arterious

inc. risk of MI and stroke, contraindicate in CABG

serious GI risk, but less with COX-2 selective

A

celecoxib

48
Q

which drug is used when NSAID therapy is required but pts are at risk of CV complications

A

naproxen

49
Q

names of some commonly used NSAIDs

A

aspirin, celecoxib, diclofenac, ibuprofen, indomethacin, ketorolac, naproxen

50
Q

Which drug has the following black box warning:

risk of medication errors and overusage can lead to hepatotoxicity with acute liver failure and death possible

A

acetaminophen

51
Q

which drug suppressed pain and fever BUT NOT inflammation

A

acetaminophen

52
Q

which drug produces a toxic metabolite when glutathione is depleted

use N-acetylcysteine as an antidote

A

acetaminophen

53
Q

What are the toxicities of pregabalin?

A

Depression, suicidal ideation

54
Q

Gaba analog like pregabalin, less reliable pharmacokinetics and more sedating

A

gabapentin

55
Q

which drug does not cause GI ulcers, does not suppress platelet aggregation, and does not impair renal function

A

acetaminophen

56
Q

which drug inhibits metabolism, therefore pt will have inc. risk of bleeding

A

acetaminophen

57
Q

What drug is used…?

For fibromyalgia, chronic musculoskeletal pain, neuropathic pain, and chemotherapy induced peripheral neuropathy.

Most benefit when SSRI do not work, for pt with concurrent depression.

A

duloxetine

58
Q

MOA of morphine (opioid)

A

binds to opioid receptors in the CNS

59
Q

which drug has the following black box warning:

respiratory depression in combination with other drugs, routes of administration

A

morphine (opioid)

60
Q

how does morphine (opioids) work

A

they inhibit the ascending pain pathways and
alter the perception of and response to pain and
cause general CNS depression

61
Q

What tricyclic antidepressant is used off-label to relieve chronic fatigue syndrome related sleep disturbances and pain among other things?

A

Amitriptyline

62
Q

What drug are these black box warning and 1 additional side effect of?

Increased risk of suicidal thinking and behavior in children, adolescents, and young adults.

Anticholinergic effects (constipation, xerostomia, blurred vision, urinary retention)

A

amitriptyline

NMSP (3 decks)

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