Pain mgmt non opioid focused pharm lecture Flashcards
acetaminophen MOA
not well understood
- blocks prostaglandin release
- raises pain threshold
- not anti-inflammatory
- analgesic, antipyretic
regular strength APAP dose
325-650 mg
q4-6 hours prn pain
extra strength APAP dose
1000 mg
q6 hr prn pain
Max daily dose APAP
4g otherwise OD! (adults)
kids 5 doses of 50-75 mg/kg max
3 main things to education pts about with tylenol
- liver warning
- alcoholic bev not recommended (esp. 3+ drinks)
- watch out combo products
alcoholics and APAP
dose lower assume already have some liver damage
APAP is metabolixed to
NAPQI (n-acetyle etc..)
how does viral illness impact APAP metablosims
increased risk toxicity if dehydrated
early sx APAP OD
N/V
AMS
metabolic acidosis
increased PT/INR (liver damage)
stage 1 APAP toxicity
asymptomatic
LFT normal
N/V, diaphoretic, pallor, malaise etc
stage 2 APAP tox
AST over 1000
RUQ pain
increased PT, bilirubin, sCr, BUN
proteinuria, hematuria, casts
stage 3 APAP tox
-max liver injury 72-96 hr post ingestion
-coma
-high ammonia level
-fatal 3-5 days post APAP OD
multiorgan failure
stage 4 APAP OD
recovery hepatic regeneration days to wks
APAP OD suspect first step?
- rumack matthew nomogram
- for acute OD in pt over 12
- estimate level of toxicity
- use w/in 4-24 hrs
- above line need NAC
NAC must be given w/in ___hrs of APAP OD
8
NAC adminstered
IV or oral
less ADR with oral
NSAIDS block __ enzymes
COX enzymes
COX enzymes do what
create prostaglandins
what do prostaglandins do
- released creating pain, inflammation, and pyretic properties
- induce uterine contractions with labor
- maintain renal blood flow (chronic NSAID use RF for renal ischemia AKI)
why no NSAID third trimester of pregnancy?
- can cause premature closure PDA
- impact placenta detachment
what is best pain reliever for post marathon pain?
APAP
- NSAID will block inflammatory response of muscle repair process, and will compromise blood flow to kidneys risk of renal ischemia
t/f enteric coated NSIADS should not be taken with milk or antacids
true
T/F nsaids take with food
yes decrease GI ADR
those that are on chronic NSAID what think about?
- GI Risk ulcers, dyspepsia, bleeds
- rx: PPIs to reduce risk
ASA/omeprazole
brand and indication?
brand: Yosprala
indicated for ppl who need ASA for CV risk but at risk for ulcers
G6PD what drugs avoid?
APAP NSAIDS FQ Sulfas dimenhydramine
can lead to hemolysis in pt who RBC already shorter lifespan
misoprostol brand
cytotec
misoprostol is a ___
synthetic prostaglandin E1 analog
misoprostol functions
- inhibits gastric acid secretion
- protects GI mucosa
- reduce incidence gastric and duodenal ulcers
- abortifacient
- teratogenic
how does misoprostol lead to abortion ?
induces labor
or
uterine rupture after 8 wk pregnant
if rx misoprostol what needs to be documented?
- advised pt risk abortion if pregnant
- do not share with others
- negative pregnancy test 2 wks prior to start
- pt capable comply with contraceptive measures
- pt got oral and written warnings of hazards
- pt will start misoprostol only on second or third day of next period
t/f celecoxib (celebrex) found to increase risk of CV events
yes
t/f diclofenac increase risk CV events
true 36%!!!
if have pt with high bp ask..?
are you taking NSAIDS?
all NSAIDS can increase BP
NSAID renal risk
AKI
hyperkalemia
Need to dose adjust for renal insufficiency
NSAIDS and ASA interaction
ibuprofen blocks antiplatelet effects of ASA
- take 30 min after ASA or 8 hrs before
List 5 classes of NSAIDS
- salicylate
- propionic acids
- carboxylic acids
- enolic acids
- cox 2 inhibitors
ex salicylates
ASA (acetylsalicylic acid)
max daily dose of ASA
4 g
tx ASA overdose
sodium bicarbonate
regular ASA dose
81 mg tab
4-8 tabs q 4 hrs max
3 propionic acids NSAIDS
- ibuprofen (advil, motrin)
- ketoprofen (orudis)
- naproxen (aleve, naprosyn, naprelan, anaprox)
advil
ibuprofen
motrin
ibuprofen
asprin
ASA
orudis
ketoprofen
aleve
naproxen
naprosyn
naproxen
anaprox
naproxen
naprelan
naproxen
max does naproxen
1500 mg daily
ibuprofen max dose
3200 mg daily
OTC max 2400mg daily
naproxen gout regimen
750 mg naproxen first
then 250 mg q8hrs until attack subsides
t/f naproxen sodium has cross reactivtivity with ASA allergy
true! ! !
6 carboxylic acids
- ketorolac
- etodolac
- diclofenac
- sulindac
- indomethacin
- nabumetone
toradol
ketorolac
acular
ketorolac
acuvail
ketorolac
sprix
ketorolac
lodine
etodolac
voltaren
diclofenac
flector
diclofenac
zipsor
diclofenac
pennsaid
diclofenac
clinoril
sulindac
indocin
indomethacin
relafen
nabumetone
why diclofenac should not be your first NSAID pick?
- increase cardiac risk
- more liver tox than most other nsaids
- more GI tox
indocin commonly used for
first line gout acute flares
close PDA in neonates
used to be used premature labor
indomethacin acute gout regimen
50 mg TID daily unitl pain improves then taper off
enolic acid NSAIDS
meloxicam (mobic)
piroxicam (feldene)
mobic
meloxicam
feldene
piroxicam
t/f meloxicam renal dose adjust?
yes
maximum daily dose of meloxicam
15 mg
indications meloxicam
- OA or RA pain relief
indications of feldene (generic?)
generic piroxicam
tx for acute and chronic RA and OA
t/f piroxicam dose adjust in hepatic impairment
true
piroxicam monitoring
- occult blood loss
- Hgb Hct
- periodic renal and hepatic function ptests
- periodic eye exams with chronic use
piroxicam max daily dose
20 mg
cox 2 inhibitors
celecoxib (celebrex)
celebrex is brand for
celecoxib
indications celecoxib
- prevention of familial adenomatous polyposis
celecoxib dosing primary dysmenorrhea or acute pain
- 400 mg initial
- additional 200mg if needed on day 1
maintanence dose 200mg BID prn
osteoarthritis celecoxib dose
100 mg / day or divided into 50 mg BID
RA celebrex dose
100-200 mg BID
t/f celebrex not recommended in pts with advanced renal disease
true
how dose adjust celebrex for hepatic impairment
decrease dose by 50% in pts with moderate hepatic impairment child pugh class II
