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PHARM II > Pain Meds > Flashcards

Pain Meds Flashcards

1
Q

what medication would you not want to take in with an OTC pain killer?

A

Tylenol (because it’s commonly combined w/ other meds for OTC painkillers & cold meds)

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2
Q

T/F, acetaminophen is an anti-inflammatory

A

False

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3
Q

MOA of acetaminophen

A

unknown: it’s an analgesic & antipyretic - raises pain threshold
(Centrally acting, may block cytokines in the dorsal horn, blocks PG release in CNS)

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4
Q

indications of acetaminophen

A
  • temporary relief of minor aches/pains

- fever reduction

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5
Q

what is acetaminophen first line for?

A

treatment of knee, hip osteoarthritis per ACR

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6
Q

Regular strength tylenol dose

A

325 – 650 mg q4 – 6h prn pain

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7
Q

Extra strength tylenol dose

A

1000 mg q6h prn pain

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8
Q

max daily dose of tylenol (adult)

A

4 g/day

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9
Q

max daily dose of tylenol (peds)

A

5 doses (50-75 mg/kg)/day (pts 12 & under)

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10
Q

why do you not want to exceed 3 alcoholic beverages per day when taking tylenol?

A

LIVER WARNING!!!

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11
Q

which tx is more effective in knee osteoarthritis, acetaminophen or hyaluronic acid inj?

A

Most effective: hyaluronic acid injections

Least effective: acetaminophen

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12
Q

what are nociceptors?

A

Primary sensory neurons that respond to noxious stimuli

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13
Q

at what age should parents talk to a PCP prior to administering tylenol to their child?

A

2 yrs/2 mos…can’t remember

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14
Q

what is the 2 step strategy for WHO Pain Treatment Peds 2012

A

Mild pain:
Acetaminophen or ibuprofen
< 3 mos of age, acetaminophen

Moderate to severe pain:
Opioids

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15
Q

which opiod is the DOC for peds w/ mod-sev pain?

A

Morphine is drug of choice (DOC)

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16
Q

why do we want to avoid giving codeine to peds?

A 
pharmacogenomic variability
(codeine is a prodrug of morphine, metabolized by 2D6)
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17
Q

why do we want to avoid tramadol in peds?

A

lack of evidence

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18
Q

what was the WHO Pain Ladder Adults 1986 originally created for?

A

CA pts

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19
Q

what’s another name for acetaminophen/tylenol?

A

paracetamol, APAP

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20
Q

what is APAP/acetaminophen metabolized by?

A

NAPQI (N-acetyl-p-benzo-quinone imine)

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21
Q

when does APAP/acetaminophen reach Cmax?

A

30 – 60 min

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22
Q

what med is the leading cause of acute liver failure in the US

A

acetaminophen

48% of acetaminophen-related cases (131 of 275) associated with accidental overdose

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23
Q

what were the majority of acetaminophen-associated OD cases from?

A

intentional overdose (70%)

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24
Q

FDA limits Rx combo meds to ___ mg acetaminophen

A

325 mg

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25
Q

what is the boxed warning for acetaminophen?

A

severe liver injury

allergic rxn

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26
Q

alcoholics
pts taking P450, 2E1 inducers
pts fasting, malnourished, dehydrated
pt’s w/ a viral illness

are at a higher risk of what, when taking APAP?

A

hepatoxicity

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27
Q

what doses of acetaminophen induce hepatoxicity?

A

10-15 g

>20 g can be fatal

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28
Q

what does TK stand for?

think PK

A

toxicity kinetics

vs pharmokinetics

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29
Q

how long after tylenol OD will serum concentrations peak?

A

4 hrs

30
Q

what organs are affected by APAP toxicity? (5)

A 
Liver (cell damage)
Renal (ATN)
Heart
Pancreas
CNS
31
Q

list the early sx of APAP toxicity (5)

A

Nausea, Vomiting, AMS (maybe), metabolic acidosis, increased PT/INR

32
Q

MOA of NSAIDs

A

Inhibit cyclooxygenase enzymes (COX)

33
Q

what are COX?

A

Prostaglandin synthase enzymes

34
Q

what is the difference between COX-1 & COX-2?

A

COX-1: Physiologic, Constitutive (found in nearly all cells at constant levels)

COX-2: Pathologic, Inducible (released in response to cell mediators; pyretic, pain, inflammatory actions)

35
Q

why is there a risk of renal ischemia w/ chronic NSAID use in pts w/ renal insufficiency, CHF or cirrhosis?

A

PGs help maintain renal blood flow in compromised kidneys & NSAIDs inhibit PG synthase enzymes

36
Q

why should pts avoid NSAIDs in their 3rd trimester?

A

PGs induce uterine contractions during labor; may cause premature closure of PDA (Patent ductus arteriosus)

37
Q

what med is used to help prevent premature labor?

A

Indomethacin

38
Q

which is better to be selective for, COX-1 or COX-2?

A

COX-2

39
Q

what pain relievers are best for runners (during/after)?

A

APAP (because NSAIDs can further damage kidneys)

40
Q

name 3 indications for NSAIDs

A
  • Acute/chronic pain (form any cause, caution w/ long-term use)
  • Cancer pain
  • Anti-inflammatory
41
Q

name some common ADRs of NSAIDs

A

Nausea, dyspepsia, anorexia, abdominal pain, flatulence, diarrhea

42
Q

how can you reduce GI SEs?

A

take w/ food/milk

enteric-coated products should not be taken with milk or antacids

43
Q

what’s the big risk w/ NSAIDs?

A

GI bleed: particulary w/ chronic use, elderly, CVD, h/o peptic ulcer or GI bleed
(ulcer, GI perf & death more rare)

44
Q

For chronic NSAID use, PPIs (-prazole) reduced risk of gastric & duodenal ulcers AND ___ & ___

A

GI bleed & dyspeptic sx

45
Q

For chronic NSAID use, double-dose H2RAs (-tidine) reduced gastric & duodenal ulcers AND ___

A

abd pain

46
Q

what is Yosprala (aspirin/omeprazole) used for?

A

patients who need ASA for CV risk, but are at risk for ulcers

47
Q

what is another concern of NSAID use? (NOT GI/kidney)

A

HF

48
Q

what is misoprostol?

A

Synthetic prostaglandin E1 analog

49
Q

MOA for misoprostol

A

Inhibits gastric acid secretion

Protects GI mucosa, reduces incidence of gastric & duodenal ulcers

50
Q

misoprostol ADRs

A

Nausea, DIARRHEA, Abdominal pain

worse w/ higher doses, ~25% pts experience SEs

51
Q

warnings for misoprostol

A

abortifacient (induction of laobr/uterine rupture after 8th wk of pregnancy
teratrogenic (preg cat X; deformities if used during 1st trimester)

52
Q

what test to you need to run before prescribing misoprostol to a female pt?

A 
pregnancy test
(need to counsel on abortive effect, document!, pt cannot share med w/ others)
53
Q

what risk is associated w/ COX-2 inhibitors?

A

CV (MI)

all NSAIDs can raise BP

54
Q

which NSAID is safest for CVE?

A

naproxen

55
Q

what is aspirin (acetylsalicylic acid)

A

Nonselective COX inhibitor

suicide inhibitor - irreversible

56
Q

what is the max daily dose of ASA?

A

4 g/day

57
Q

ASA MOA

A

Anti-platelet
Analgesic, anti-inflammatory
Anticancer?

58
Q

daily max dose of ibuprofen?

A

3200 mg/day (Rx)

2400 mg/day (OTC)

59
Q

daily max dose of naproxen?

A

1500 mg/day

60
Q

which NSAID would you especially not want to Rx if pt has an ASA allergy?

A

naproxen

61
Q

what is first-line for gout flares?

A

indomethacin
(take for up to a wk)
can also use naproxen

62
Q

3 indications for indomethacin

A

Gout flares
Close PDA in neonates
Can be used for premature labor (< 48 hrs)

63
Q

Which med is a “true COX-2 inhibitor”?

A

celecoxib

64
Q

Stage 1 APAP toxicity

A 
No liver injury
Asymptomatic or 
Early signs/symptoms
Normal LFTs
Nausea, vomiting, diaphoresis, pallor, malaise
65
Q

Stage 2 APAP toxicity

A 
Liver injury 24 - 36 hours
AST elevated (may be > 1000)
RUQ pain, hepatomegaly
Possible nephrotoxicity
Increased PT, bilirubin, sCr, BUN
Proteinuria, hematuria, casts
66
Q

Stage 3 APAP toxicity

A 
Maximum liver injury 72 to 96 hours
Hepatic failure
Encephalopathy
Coma
Hemorrhage
Nausea/vomiting may return
High ammonia level
AST/ALT elevated > 10,000 IU/L
Abnormal: PT, creatinine, Glucose, pH, Bilirubin, lactate
Fatality (Usually 3 – 5 days after OD, Multiorgan failure, Hemorrhage, ARDS, Sepsis, Cerebral edema)
67
Q

Stage 4 APAP toxicity

A

Recovery
Hepatic regeneration
Several days to weeks

68
Q

What is used to predict the likelihood of tylenol toxicity & determine the need for antidote?

A

Rumack-Matthew Nomogram

69
Q

What is the antidote for tylenol toxicity?

A

NAC (N-acetylcysteine): admin w/in 8 hrs of OD, use w/ possible/probable risk of hepatotoxicity, preg cat B

70
Q

MOA of NAC

A

Prevents hepatic injury by limiting formation of NAPQI

71
Q

NAC dosage

A

IV/PO (fewer ADR PO)
IV anaphylaxis possible: rash, urticaria, pruritus, flushing, N/V, bronchospasm, potentially fatal - antihistamines, steroids, beta agonist, epi

PHARM II (3 decks)

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