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PHA333 > pain in practice (Andrew) > Flashcards

pain in practice (Andrew) Flashcards

1
Q

observational changes with pain

A
  • autonomic changes (pallor, sweating, altered breathing, hypertension)
  • facial expressions
  • body movements
  • verbalisations/vocalisations
  • interpersonal interactions
  • changes in activity patterns
  • mental status changes
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2
Q

acute vs chronic pain

A

acute - from injury or post-operative flare

chronic - nociceptive, neiropathic, visceral, mixed

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3
Q

causes of nociceptive pain

A

OA

RA

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4
Q

causes of neuropathic pain

A

central

  • post stroke
  • MS
  • spinal cord injury
  • migraine

peripheral

  • diabetic neuropathy
  • post herpetic nerualgia
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5
Q

types of visceral pain

A

internal organs
pancreatitis
IBD

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6
Q

types of mixed pain

A

lower back
cancer
fibromyalgia

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7
Q

considerations for treatment of pain

A
  • type of pain
  • cause of pain
  • acute or chronic
  • exacerbating/relieving factors
  • non-pharmacological management
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8
Q

WHO analgesic ladder

A

step 1 - paracetamol (non-opioid)

step 2 - codeine (weak opioid), keep the paracetamol

step 3 - morphine (strong opioid), stop the weak opioid

can take NSAIDs at same time

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9
Q

NSAID choice

A

ibuprofen
naproxen
(non selective COX inhibitors)

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10
Q

coxibs

A

celecoxib
etoricoxib
-> selective COX2 inhibitors

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11
Q

aspirin MOA

A

standard NSAID and blocks thromboxane production (anti-platelet)

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12
Q

examples of weak opioids

A

codeine
dihydrocodeine
tramadol

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13
Q

tramadol MOA and schedule

A

Sch 3 CD

inhibits NA and serotonin uptake

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14
Q

analgesics under 16 yrs

A 
1st line (>3mths) - paracetamol/ibuprofen monotherapy
-> check adherance and dose before increasing

2nd line - paracetamol and ibuprofen together

3rd line - specialist advice

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15
Q

choice of analgesics in adults

A

1st line

  • paracetamol 1g QDS
  • OR ibuprofen 400mg TDS max 2.4g daily

2nd line
- paracetamol and ibuprofen

3rd line

  • alternative NSAID
  • eg. naproxen 250-500mg BD

4th line

  • weak opioid
  • eg. codeine up to 60mg QDS with paracetamol +/- NSAID

**consider PPI with NSAID

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16
Q

key points with NSAIDs

A
  1. don’t use themunless yuo have to
  2. if you have to use them, use them carefully
  3. consider gastroprotection in high risk patients
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17
Q

How to use NSAIDs carefully?

A
  • assess CV/GI/renal risk
  • use a safer drug in lowest effective dose for shortest possible time
  • med review
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18
Q

gastroprotection for NSAIDs (esp. over 65)

A

PPIs
double dose H2RAs
misoprostol

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19
Q

dose of codeine

A

30-60mg every 4hrs

max 240mg in 24hrs

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20
Q

dose of dihydrocodeine

A

30mg every 4-6hrs

max 240mg in 24hrs

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21
Q

dose of tramadol

A

50-100mg every 4hrs

max 400mg in 24hrs

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22
Q

When to use lower dose of weak opioids?

A

elderly
CKD
hypothyroidism
adrenalcorticoid insufficiency

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23
Q

adverse effects of weak opioids

A
  • CNS depression (sedation, caution driving etc)
  • GI (nausea, vomiting, constipation)
  • dependence/tolerance (max 3 days OTC, caution in suspected dependence/repeat purchases/withdrawal symptoms)
  • tramadol s/e
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24
Q

s/e of tramadol

A 
seizures
hallucinations
confusion
hyponatraemia
hypoglycaemia
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25
interactions with weak opioids
- caution with other CNS depressants/alcohol - MAOI (avoid during and 2 weeks after stopping) - tramadol
26
tramadol interactions
- drugs that lower seizure thershold (TCA, carbamazepine) - warfarin (raised INR) - SSRIs (serotonin syndrome, inc seizure risk)
27
strong opioids (1st line)
morphine oral - IR liquid/tabs - MR (OD/BD) morphine (parenteral) diamorphine (parenteral)
28
forms of morphine
IR - Oramorph morphine sulphate oral solution (10mg/5ml) - Oramorph concentrated morphine sulphate oral solution (20mg/ml) - Sevredol tabs (10/20/50mg) 12hr MR - MST Continus tabs - Zomorph caps 24hr MR - MXL caps
29
dose of strong opioid for chronic pain
initiation - 5-10mg every 4hrs of IR morphine adjusted according to response adjustments - no more than one third/half of total daily dose ever 24hrs aim = lowest effective dose based on symptom control and s/e
30
How to convert to MR dose of morphine?
1. get total daily dose of morphine 2. give same total daily dose but MR product 3. calculate appropriate breakthrough dose
31
How to convert to MR dose of morphine?
1. get total daily dose of morphine 2. give same total daily dose but MR product 3. calculate appropriate breakthrough dose
32
usual dose in practice when changing to MR morphine
start with 10-20mg MR BD and titrate but continue IR when required
33
When is breakthrough dose used?
acute flare up of pain/anticipation of increased pain eg. changing a dressing
34
breakthrough dose of morphine
1/6th - 1/10th of the total daily dose of morphine
35
When is morphine given parenterally?
patient unable to swallow GI dysfunction
36
How is morphine given parenterally?
IM or SC every 4hrs
37
IR morphine to SC/IM
give 50% of the dose and same frequency
38
MR morphine to IM/SC
give 50% of total daily dose | divide and administer every 4hrs
39
IM/SC dose of IR morphine 60mg MST BD
60mg MST BD = 120mg morphine daily 50% = 60mg give 10mg IM/SC every 4hrs
40
diamorphine parenterally
highly soluble opioid used for high dose SC injections powder preparation is diluted in small volume of water for injection
41
adverse effects of strong opioids
- euphoria (initially) - drowsiness - n&v (Rx anti-emetics) - constipation (90% pts, Rx laxatives with strong opioids) - tolerance - addiction - respiratory depression
42
Why would you give alternatives of strong opioids?
- management of more difficult pain - side effects (patient tolerability) - alternative drug preparation (might benefit from patch etc.) - drug profile (renal impairment, can accumulate)
43
alternatives of morphine for strong opioids
``` oxycodone fentanyl patch alfentanil buprenorphine (patch) hydromorphone ```
44
What is oxycodone?
semi-synthetic analogue of morphine different profile strong kappa agonist mu agonist
45
metabolite of oxycodone
metabolised to oxymorphone -> caution in hepatic impairment
46
potency of oxycodone
1.5x as potent as morphine 2x as potent SC as oral
47
oxycodone in renal impairment
clearance of drug and metabolites is reduced
48
When can oxycodone used?
2nd line difficult pain MILD renal impairment
49
forms of oxycodone
IR caps and liquid MR tabs injection
50
What is fentanyl patch?
semi-synthetic analogue of morphine potent mu agonist highly liphophilic
51
metabolite of fentanyl
norfentanyl
52
fentanyl patch and renal impairment
safe
53
When can fentanyl patch be used?
2nd line STABLE PAIN side effects (constipation) renal impairment
54
caution with fentanyl patch
when converting from other opioids and titrating dose
55
How to apply a fentanyl patch?
- non-hairy, non-irritated, non-irradiated skin, flat surface of torso or upper arm - skin cleaned with water only, completely dry before applying - don't use cut/divided/damaged patches - apply for 72hrs (3 days) then a new one applied to a different site - safe disposal - patient stay on SAME BRAND
56
How to use fentanyl patch for 1st time?
- wear for 24hrs to see the analgecis effect (gradual inc in plasma fentanyl conc) - phase out other analgesia gradually from 1st patch - close monitoring of efficacy and s/e - dose adjusted at 48-72hr intervals in steps of 12-25mcg/hr if necessary - can use more than one at a time (apply at same time)
57
Who should only use fentanyl patches?
patient who is stable on morphine
58
morphine equivalent to fentanyl patches
``` morphine 30mg = fentanyl 12 patch morphine 60mg = fentanyl 25 patch morphine 120mg = fentanyl 50 patch morphine 180mg = fentanyl 75 patch morphine 240mg = fentanyl 100 patch ```
59
How to convert from morphine to fentanyl patches?
1. calculate daily dose of MR morphine 2. check equivalence chart - > usually 25-50% reduction in dose to ensure safety (lower mcg patch) 3. calculate appropriate beakthrough dose (as morphine oral solution or oxycodone solution)
60
breakthrough dose foe fentanyl 75mcg patch
75mcg = 180mg morphine ``` 1/10th = 18mg 1/6th = 30mg ``` (20mg PRN appropriate)
61
other forms of fentanyl (specialist Rx)
buccal sublingual intranasal
62
What is alfentanil?
synthetic derivative of fentanyl more rapid onset shorter duration of action (less liphophilic)
63
potency of anfeltanil
1/4 of fentanyl | 10x SC diamorphine
64
alfentanil in renal impairment
safe
65
Wehn is anfentanil used?
2nd line renal failure SC PRN short acting
66
preparation of alfentanil
injection
67
What is buprenorpheine?
semi-synthetic analogue of morphine partial mu agonist kappa antagonist delta antagonist
68
metabolites of buprenorphine
norbuprenorphine | others
69
2 brands of buprenorphine
Transtec | BuTrans
70
Transtec potency
low dose strong opioid 35mcg = 30-60mg PO morphine
71
BuTrans potency
weak opioid 5mcg = 30-60mg PO codeine
72
durations of buprenorphine preparations
Transtec 4 days BuTrans 7 days
73
When is buprenorphine used?
2nd line stable pain low dose
74
What is hydromorphone?
semi-synthetic analogue of morphine potent mu selective agonist
75
metabolites of hydromorphone
H3G | other minor ones
76
potency of hydromorphone
7.5x PO morphine 2x as potent as SC as PO -> SC unlicenced
77
hydromorphone in renal impairment
clearance unchanged but metabolites accumulate
78
preparation of hydromorphone
capsules
79
When is hydromorphone used?
2nd line | mild/moderate renal impairment
80
What can cause neuropathic pain?
``` infection inflammation metabolic diseae trauma compression chemical induced nerve damage ```
81
CNS neuropathic pain (brain/spinal cord)
traumatic spinal cord injury central post stroke pain pain associated with a degenerative disease
82
PNS neuropathic pain
diabetic polyneuropathy (DPN) postherpetic neuralgia (PHN) HIV sensory neuropathy carpal-tunnel syndrome
83
presentation of neuropathic pain
burning constant pain stabbing paroxysmal attacks signs of hypersensitivity on clinical examination
84
Do opioids and anti-inflammatories work for neuropathic pain?
NO
85
consequences of neuropathic pain
psychological | reduction in QoL
86
pain ladder for neuropathic pain
1st line - tricyclic antidepressants - OR antiepileptic (only 1 drug) 2nd line - tricyclic antidepressat and antiepileptic (combination) 3rd line - strong opioids (alone or combination with prevoius drugs) - +/- invasive procedures -> implantable pump, dorsal colum stimulator
87
tricyclic antideressant for neuropathic pain
amitriptyline
88
How does amitriptyline work?
blocks pre-synaptic reuptake of NTs (Sr, NA) maybe NMDA receptor antagonist
89
How long does it take amitriptyline to work?
3-7 days
90
side effects of amitriptyline
antimuscarinic - dry mouth - confusion - constipation
91
dose of amitryptyline
10mg nocte | up to 75mg nocte
92
alternatice TCAs for neuropathic pain
imipramine nortriptyline
93
antiepileptics used for neuropathic pain
gabapentin pregabalin
94
How do antiepileptics work?
chemical analogue of GABA bind to site in CNS interact with alpha delta Ca channels in CNS
95
antiepileptics and renal impairment
renally excreted | -> caution
96
s/e of antiepileptics
drowsy | dizziness
97
pharmacokinetics of gabapentin
- nonlinear and dose dependent profile of absorption - higher inter subject variability to the absolute bioavailability - slow individual titration 100mg nocte max 3,6g daily divided doses
98
pharmacokinetics of pregabalin
- linear pharmacokinetic profile - 90% bioavailability - more predictable - onset of pain relief quicker
99
licence for duloxetine
diabetic neuropathy
100
How does duloxetine work?
selective inhibitor of serotonin and noradrenaline reuptake
101
dose of duloxetine
60mg daily | max 120mg
102
What metabolises duloxetine?
CYP 450 enzymes
103
s/e fo duloxetine
``` nausea dry mouth constipation insomnia dizziness drowsy ```
104
NICE recommendations for neuropathic pain
- offer choice of amitriptyline, duloxetine, gabapentin or pregabalin - try another - tramadol for acute rescur therapy only - capsaicin cream if oral agent unsuitable - carbamazepine for trigeminal neuralgia
105
options for neuropathic pain speaiclist Rx
ketamine methadone
106
other treatment for bone pain in cancer/bone disease
bisphosphonates calcitonin radiopharmaceuticals
107
other treatments for MSK pains
muscle relaxants benzodiazepines
108
non-drug pain relief
``` heat/cold massage TENS radiotherapy nerve blocks acupuncture psychological therapies ```

PHA333 (27 decks)

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