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Pharmacology > Pain Modalities > Flashcards

Pain Modalities Flashcards

1
Q

What is the 1st line treatment for pain persisting or increase in after giving a non-opioid medication?

A

And opioid for mild-moderate pain (+) an non-opioid. (+) adjuvant.

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2
Q

AEDs and TCAs can be effective as adjuvants in managing which type of pain?

A

Chronic Visceral pain not controlled by opioids.

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3
Q

Clonidine or baclofen can be effective in managing what type of pain?

A

Chronic central neuropathic pain.

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4
Q

Lidocaine, SSRI or SNRI can be effective adjuvants in managing which type of pain?

A

Chronic, peripheral neuropathic pain.

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5
Q

If APAP or NSAIDS have not worked to control chronic inflammatory pain, what is the next line of medication?

A

Long-acting opioids such as OxyContin.

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6
Q

What is a good expectation to set for chronic non-cancer pain management?

A

Goal is LOW pain rather than NO pain.

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7
Q

Medications that work on Peripheral sites of action work to__________
Medications that work on supra-spinal sites of action work to _________

A

Reduce sensory INPUT to CNS

Reduce excitatory transmission FROM CNS.

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8
Q

Which medications work on he prostanoid pathway?

A

NSAIDS - Cox1and/or 2 inhibitors
Corticosteroids
Acetaminophen

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9
Q

What prostanoids are needed to make “inflammatory soup” ?

A

Prostaglandins
Prostacyclin (PGI2)
Thromboxane (TXA2)

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10
Q

What steps need to happen in order to create “prostaglandin soup” and what medications inhibit these steps?

A
  1. Inflammatory stimuli = Ca++ converting phospholipase A2 to Arachodonic acid (corticosteroids work here)
  2. Arachadonic acid (AA) convert COX 1 or 2 to PGG2 (unstable intermediate). NSAIDS work here to occupy AA binding sites.
  3. PGG, HETEs and POX work to create PGH2 which leads to prostanoid creation . APAP works here.
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11
Q

Tylenol #3 and #4 include _____

A

Codeine

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12
Q

T/F: Tylenol provides an anti-inflammatory effect

A

False.

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13
Q

Which types of NSAIDS are associated with less GI and bleeding side effects? Why?

A

Selective COX2 inhibitors.

Blocking COX1 decreases TXA2 which is required for platelet activation and aggravation = higher bleeding risk.

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14
Q

Why should you avoid NSAIDs in the 3rd Trimester of pregnancy?

A

Premature closure

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15
Q

What are the COX1+2 non-selective NSAIDS?

A

Ibuprofen, advil, naproxen, ketorolac.

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16
Q

What NSAID is popular for post-surgical use?

A

Ketorolac.

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17
Q

What are COX2 selective NSAIDs?

A

Celecoxib, Diclofenac, Meloxicam

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18
Q

What is arthrotec and when should it be avoided?

A

Diclofenac + misoprostal = avoid in females of childbearing potential.

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19
Q

When should celebrex be used? What is it CI?

A

OA and RA
Sullfonamide allergy

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20
Q

Irreversible COX1+2 NSAIDs

A

Aspirin, Excedrin

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21
Q

What can be taken with NSIADs to protect the gut

A

PPIs.

22
Q

What other meds should be avoided with NSAID use?

A

Steroids, anticoagulants, aminoglycosides, and IV loop diuretics.

23
Q

What is the MOA of Tramadol and tapentadol?

A

Mu-opioid receptor agonists and inhibitors of NE/serotonin reuptake

24
Q

What are some DIs of Tramadol?

A

Other CYP2D6 inhibitors (respiratory depression and death)
AEDs
Serotonergic drugs
Warfarin = increased INR

25
Q

What are the agents of choice for severe acute pain or mod-severe cancer associated pain?

A

Opioid analgesics.

26
Q

Codeine is a prodrug of ______. This means _______

A

Morphine
Death in children who are r ultra-rapid metabolizers of morphine
Death in nursing infants of mothers who are ultra-rapid metabolizers.

27
Q

Dosage for codein

A

15-60mg Q4h PRN

28
Q

Fentanyl is NOT for use in

A

Opioid naive users.

29
Q

Fentanyl dosage

A

1 patch Q 72hrs

30
Q

Hydromorphone is most commonly used in ____________. Dosage?

A

Epidurals and PCAs.
Oral: 2-4mg Q4-6H PRN
IV 0.2-1mg Q2-3H PRN

31
Q

What medication class is methadone?
Used for?
Dose?
AEs?

A

Opioids
Detox and tx of opioid use disorder
2.5-10mg Q8-12h
AE - QT prolongation, sexual dysfunction related to testosterone decrease.

32
Q

Morphine dosages

A

IR tab: 10-30 Q4H PRN
ER tab: 15, 30, 60, 100, 200mg Q8-12H PRN
IV: 2.5-5mg Q3-4H PRN.

33
Q

Oxycodone dose?
CI?

A

IR tab- 5-20mg Q4-6H
CR tab 10-80mg Q12H
Moderate/severe liver impairment

34
Q

What opioid should be taken on an EMPTY stomach?

A

Oxycodone. (Percocet, Endocet, Roxycodone, OxyContin)

35
Q

What other drugs do you not want to mix with opioids?

A

Alcohol, hypnotics, benzos, muscle relaxants (any CNS depressants)

36
Q

Which opioids are CYP3A4 Substrates?

A

Hydrocodone, fentanyl, methadone and Oxycodone (MOHF)

37
Q

What are some reasons opioids may need to be converted?

A

Dose increase needed,
SEs intolerable
Unaffordable drug
Changing from IV to PO

38
Q

What is a key thing to remember when converting IV fentanyl to patch?

A

Patches are in mcg/hr while IV is mg. So you need to multiply by 1000 then divide by 24hrs.

39
Q

5 steps to convert IV/IM opioid to PO

A
  1. Calculate 24hr dose of current drug
  2. Ratio-conversion to calculate the dose of new drug
  3. Calculate 224hr dose of new drug and reduce by at least 25%
  4. Divide by the new drug’s appropriate interval dose
  5. BTP dosing is 10-15% of total daily baseline.
40
Q

Ex of dosing conversion:
Hydromorphone IV 1.5mg to oral morphine 30mg

A

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

41
Q

Main SE for all opioids?
1st line?
2nd line?
Alternative?

A

Opioid induced constipation (OIC)

Tx with First -line (stimulant - bisacodyl) or osmotic (Mirilax) laxatives

2nd line = PAMORAs (Methylnaltrexone, Nalgene dine, naloxegol

Alternative Lubiprostone

42
Q

Narcan dosing

A

0.4mg IV Q2-3min

43
Q

What class of med is Gabapentin? Dosage?

A

AED 300mg TID

44
Q

What are the 3 AEDs used as adjuvants for neuropathic pain?

A

Gabapentin (300mg TID)
Pregabalin (75mg BID)
Carbamazepine (100mg BID)

45
Q

What medication is FDA approved for Trigeminal neuralgia? What is it’s MOA?

A

Carbamazepine. Lowers the polysynaptic nerve response by inhibiting tetanic potentiation which stabilizes the signals your nerve sends out.

46
Q

What are SNRI/TCAs approved as adjuvants for neuropathic pain?

A

Amitriptyline - 10-50mg QHS
Duloxetine (Cymbalta) 30-60mg/day

47
Q

What is Gabapentin’s MOA?

A

Unique ability to effect the voltage-dependent calcium channels at the postsynaptic dorsal horns which interrupts neuropathic pain sensation.

48
Q

What is a SE for all MSK pain/spasm adjuvants?

A

Sedation

49
Q

What is Carisoprodol?

A

An antispasmodic used as adjuvant for MKS pain/spasm.

50
Q

Antispasmodic Adjuvants for MSK pain/spasms

A

Baclofen, Cyclobenzaprine (flexeril), Tizanidine, Carisoprodol, Methocarbamol.

Pharmacology (20 decks)

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