Pain Modalities Flashcards
What is the 1st line treatment for pain persisting or increase in after giving a non-opioid medication?
And opioid for mild-moderate pain (+) an non-opioid. (+) adjuvant.
AEDs and TCAs can be effective as adjuvants in managing which type of pain?
Chronic Visceral pain not controlled by opioids.
Clonidine or baclofen can be effective in managing what type of pain?
Chronic central neuropathic pain.
Lidocaine, SSRI or SNRI can be effective adjuvants in managing which type of pain?
Chronic, peripheral neuropathic pain.
If APAP or NSAIDS have not worked to control chronic inflammatory pain, what is the next line of medication?
Long-acting opioids such as OxyContin.
What is a good expectation to set for chronic non-cancer pain management?
Goal is LOW pain rather than NO pain.
Medications that work on Peripheral sites of action work to__________
Medications that work on supra-spinal sites of action work to _________
Reduce sensory INPUT to CNS
Reduce excitatory transmission FROM CNS.
Which medications work on he prostanoid pathway?
NSAIDS - Cox1and/or 2 inhibitors
Corticosteroids
Acetaminophen
What prostanoids are needed to make “inflammatory soup” ?
Prostaglandins
Prostacyclin (PGI2)
Thromboxane (TXA2)
What steps need to happen in order to create “prostaglandin soup” and what medications inhibit these steps?
- Inflammatory stimuli = Ca++ converting phospholipase A2 to Arachodonic acid (corticosteroids work here)
- Arachadonic acid (AA) convert COX 1 or 2 to PGG2 (unstable intermediate). NSAIDS work here to occupy AA binding sites.
- PGG, HETEs and POX work to create PGH2 which leads to prostanoid creation . APAP works here.
Tylenol #3 and #4 include _____
Codeine
T/F: Tylenol provides an anti-inflammatory effect
False.
Which types of NSAIDS are associated with less GI and bleeding side effects? Why?
Selective COX2 inhibitors.
Blocking COX1 decreases TXA2 which is required for platelet activation and aggravation = higher bleeding risk.
Why should you avoid NSAIDs in the 3rd Trimester of pregnancy?
Premature closure
What are the COX1+2 non-selective NSAIDS?
Ibuprofen, advil, naproxen, ketorolac.
What NSAID is popular for post-surgical use?
Ketorolac.
What are COX2 selective NSAIDs?
Celecoxib, Diclofenac, Meloxicam
What is arthrotec and when should it be avoided?
Diclofenac + misoprostal = avoid in females of childbearing potential.
When should celebrex be used? What is it CI?
OA and RA
Sullfonamide allergy
Irreversible COX1+2 NSAIDs
Aspirin, Excedrin
What can be taken with NSIADs to protect the gut
PPIs.
What other meds should be avoided with NSAID use?
Steroids, anticoagulants, aminoglycosides, and IV loop diuretics.
What is the MOA of Tramadol and tapentadol?
Mu-opioid receptor agonists and inhibitors of NE/serotonin reuptake
What are some DIs of Tramadol?
Other CYP2D6 inhibitors (respiratory depression and death)
AEDs
Serotonergic drugs
Warfarin = increased INR
What are the agents of choice for severe acute pain or mod-severe cancer associated pain?
Opioid analgesics.
Codeine is a prodrug of ______. This means _______
Morphine
Death in children who are r ultra-rapid metabolizers of morphine
Death in nursing infants of mothers who are ultra-rapid metabolizers.
Dosage for codein
15-60mg Q4h PRN
Fentanyl is NOT for use in
Opioid naive users.
Fentanyl dosage
1 patch Q 72hrs
Hydromorphone is most commonly used in ____________. Dosage?
Epidurals and PCAs.
Oral: 2-4mg Q4-6H PRN
IV 0.2-1mg Q2-3H PRN
What medication class is methadone?
Used for?
Dose?
AEs?
Opioids
Detox and tx of opioid use disorder
2.5-10mg Q8-12h
AE - QT prolongation, sexual dysfunction related to testosterone decrease.
Morphine dosages
IR tab: 10-30 Q4H PRN
ER tab: 15, 30, 60, 100, 200mg Q8-12H PRN
IV: 2.5-5mg Q3-4H PRN.
Oxycodone dose?
CI?
IR tab- 5-20mg Q4-6H
CR tab 10-80mg Q12H
Moderate/severe liver impairment
What opioid should be taken on an EMPTY stomach?
Oxycodone. (Percocet, Endocet, Roxycodone, OxyContin)
What other drugs do you not want to mix with opioids?
Alcohol, hypnotics, benzos, muscle relaxants (any CNS depressants)
Which opioids are CYP3A4 Substrates?
Hydrocodone, fentanyl, methadone and Oxycodone (MOHF)
What are some reasons opioids may need to be converted?
Dose increase needed,
SEs intolerable
Unaffordable drug
Changing from IV to PO
What is a key thing to remember when converting IV fentanyl to patch?
Patches are in mcg/hr while IV is mg. So you need to multiply by 1000 then divide by 24hrs.
5 steps to convert IV/IM opioid to PO
- Calculate 24hr dose of current drug
- Ratio-conversion to calculate the dose of new drug
- Calculate 224hr dose of new drug and reduce by at least 25%
- Divide by the new drug’s appropriate interval dose
- BTP dosing is 10-15% of total daily baseline.
Ex of dosing conversion:
Hydromorphone IV 1.5mg to oral morphine 30mg
30mg PO morphine
—
1.5mg IV hydromorphone
=
X mg oral morphine
—
12mg IV hydromorphone (24hr)
X = 240mg morphine PO
50%of 240 = 120mg/day. Since morphine ER dose is 60mg BID.
15mg IR morphine for BTP
Main SE for all opioids?
1st line?
2nd line?
Alternative?
Opioid induced constipation (OIC)
Tx with First -line (stimulant - bisacodyl) or osmotic (Mirilax) laxatives
2nd line = PAMORAs (Methylnaltrexone, Nalgene dine, naloxegol
Alternative Lubiprostone
Narcan dosing
0.4mg IV Q2-3min
What class of med is Gabapentin? Dosage?
AED 300mg TID
What are the 3 AEDs used as adjuvants for neuropathic pain?
Gabapentin (300mg TID)
Pregabalin (75mg BID)
Carbamazepine (100mg BID)
What medication is FDA approved for Trigeminal neuralgia? What is it’s MOA?
Carbamazepine. Lowers the polysynaptic nerve response by inhibiting tetanic potentiation which stabilizes the signals your nerve sends out.
What are SNRI/TCAs approved as adjuvants for neuropathic pain?
Amitriptyline - 10-50mg QHS
Duloxetine (Cymbalta) 30-60mg/day
What is Gabapentin’s MOA?
Unique ability to effect the voltage-dependent calcium channels at the postsynaptic dorsal horns which interrupts neuropathic pain sensation.
What is a SE for all MSK pain/spasm adjuvants?
Sedation
What is Carisoprodol?
An antispasmodic used as adjuvant for MKS pain/spasm.
Antispasmodic Adjuvants for MSK pain/spasms
Baclofen, Cyclobenzaprine (flexeril), Tizanidine, Carisoprodol, Methocarbamol.
