Pain Drugs (Wolff)

Question 1

What are the 4 NSAIDs used to treat mild to moderate and moderate to severe nociceptive pain?

Answer 1

aspirin
ibuprofen
naproxen (long half-life)
celecoxib

Question 2

Nociceptive pain

Answer 2

perception of input from a nociceptor
if somatic - injury to body tissues: well localized and sharp
if visceral - viscera stretch receptor: poorly localized, deep, dull and cramping

Question 3

Neuropathic pain

Answer 3

abnormal neural activity secondary to disease, injury or dysfunction of the nervous system

Question 4

aspirin

Answer 4

irreversibly inhibits COX-1 and 2; NSAID used for nociceptive pain; toxicities - ulcer, increased risk of bleeding, increased risk of Reye syndrome

Question 5

Reye syndrome

Answer 5

A rare but serious condition that causes confusion, swelling in the brain, and liver damage (kids); can be triggered by aspirin

Question 6

Which agent used to treat pain can trigger Reye syndrome?

Answer 6

aspirin

Question 7

ibuprofen

Answer 7

non-aspirin NSAID; reversibly inhibits COX-1 and 2; management of pain; increased risk for MI and stroke (contraindicated in CABG); increased risk of GI bleed and not recommended around 20 weeks gestation or later in pregnancy (fetal renal dysfunction)

Question 8

What is a feared complication of non-aspirin NSAIDs in pregnancy

Answer 8

20 weeks gestation of later due to potential to cause fetal renal dysfunction leading to oligohydramnios

Question 9

Celecoxib

Answer 9

non-aspirin NSAID; reversible inhibits COX-2 (not COX-1); does NOT inhibit platelet aggregation (no risk of bleeding); increased risk of MI and stroke

Question 10

According to the American Heart Association, what is the NSAID of choice?

Answer 10

naproxen (longer half-life); use the lowest effective dosage for the shortest possible time

Question 11

acetaminophen

Answer 11

agent used to treat minor aches, pains and headache and moderate to severs pain (does NOT suppress inflammation); MOA not fully known; toxic metabolite when glutathione is depleted; risk of medication errors can cause overdosage and hepatotoxicity with acute liver failure and death

Question 12

agent used in acetaminophen toxicity?

Answer 12

N-acetylcysteine

Question 13

Treatment for nociceptive pain?

Answer 13

NSAIDS and acetominophen

Question 14

The 3 first line treatments for neuropathic pain?

Answer 14

Antidepressants: 1. SNRI-duloxetine or 2. TCA-amitriptyline
or 3. Ca2+ ch alpha 2 delta inhibitors - pregabalin or gabapentin

Question 15

SNRI

Answer 15

serotonin-NE reuptake inhibitor; anti-depressant; duloxetine

Question 16

duloxetine

Answer 16

anti-depressant serotonin-NE reuptake inhibitor (SNRI); used for fibromyalgia and neuropathic pain; increased risk of suicidal thoughts and behaviors

Question 17

TCA

Answer 17

tricyclic antidepressants; amitriptyline - used to treat neuropathic pain

Question 18

amitriptyline

Answer 18

tricyclic antidepressants used to treat neuropathic pain and chronic fatigue syndrome; increased risk of suicidal thoughts and behaviors, anticholinergic effects, serotonin withdrawal and withdrawal syndrome

Question 19

CNS alpha-2-delta Ca2+ channel blockers

Answer 19

pregabalin and gabapentin - does NOT bind GABA receptors!

Question 20

Pregabalin

Answer 20

CNS alpha-2-delta Ca2+ channel blocker (does NOT bind GABA receptors!); first-line agent used in neuropathic pain, fibromyalgia, diabetic neuropathy, seizures; pain benefits evident in 1st week; depression and suicidal ideation

Question 21

Second line treatments for neuropathic pain?

Answer 21

antidepressant + u agonist - Tramadol and Tapentadol

Question 22

antidepressant + u agonist

Answer 22

Tramadol (partial u agonist - weak) and Tapentadol (u against - strong)

Question 23

Tramadol

Answer 23

Second line treatments for (severe) neuropathic pain; antidepressant + partial u agonist; multiple back box warnings - risk of errors/ingestion by children - OD and death (respiratory depression); addiction, abuse and misuse; withdrawal syndrome; risk of respiratory depression

Question 24

Third line treatments for neuropathic pain?

Answer 24

NMDA antagonists - Ketamine
Selective alpha 2 agonists - Dexmedetomidine and Clonidine

Question 25

Ketamine

Answer 25

noncompetitive NMDA receptor antagonist; blocks glutamate; can go into a cataleptic-like state (dissociation from surrounding environment); used for acute and chronic pain and indicated in general anesthesia; requires careful monitoring

Question 26

Which neuropathic agent can cause a patient to go into a cataleptic-like state?

Answer 26

Ketamine; noncompetitive NMDA receptor antagonist; blocks glutamate; dissociation from surrounding environment; used for acute and chronic pain and indicated in general anesthesia; requires careful monitoring

Question 27

Dexmedetomidine

Answer 27

Selective alpha 2 agonists in the brainstem; a potent anxiolytic used in postoperative pain management; can cause significant harm when used in error

Question 28

Clonidine

Answer 28

Selective alpha 2 agonists in the brainstem; used for hypertension and as epidural pain relief; administered by continuous infusion through an epidural catheter

Question 29

Fourth line treatments for neuropathic pain?

Answer 29

Botulinum toxin injections or intrathecal ziconotide

Question 30

Ziconotide

Answer 30

N-type VG Ca2+ channel blockers on afferent nerves of the dorsal horn; 4th line treatment in neuropathic pain (severe chronic pain); VERY expensive - intrathecal route; severe psychiatric symptoms and neurological impairment

Question 31

Botulinum Toxin

Answer 31

decreases the release of acetylcholine at 4 sites: NMJ, autonomic ganglia, postganglionic parasympathetic nerve endings and postganglionic sympathetic nerve endings that release Ach

Question 32

What are the two anti-migraine medications?

Answer 32

Sumatriptans (triptans) and dihydroergotamine

Question 33

dihydroergotamine

Answer 33

late treatment option for migraines; can cause “St. Anthony’s fire” - behavioral disturbances and pain and distal gangrene in fingers, nose, penis and toes