Pain part 1 and part 2 Flashcards
What systems affect by NSAIDS?
GI, Renal, CV
Cox 2 inhibition effect?
Anti-inflammatory
analgesic
Cox-1 and Cox-2 inhibition effects?
antipyretic
anelgesic
When does Cox-2 is induced?
during injury or surgery
List the generic name for NSAID?
Asprin, Ibuprofen, Naproxen, Indomethacin, Diclofenac, Celecoxib, Meloxicam
Aspirin indications
analgesia, antipyretic, anti-inflammatory, antithrombotic
Aspirin MOA
irreversibly inhibits Cox-1 and Cox-2,
decrease formation of prostaglandin precursors (thromboxane A2= decrease platelet aggregation)
At low dose aspirin is….
selective for Cox-1= cardio protection
What do you do get anti-inflammatory and analgesia effects when taking asprin?
increase dosage
Aspirin AE
GI (N/V(nausua or vomiting), dyspepsia, ulcers, bleeding), bleeding/bruising; rare- skin rash, photosensitivity, bronchospasm
When should you avoid Aspirin
history of GI bleed , adolescents with recent flu/viral illness (Reye’s syndrome)
NSAIDs indications
analgesia, antipyretic, anti-inflammatory
NSAIDs MOA
reversibly inhibits COX-1 and Cox-2 enzymes
Which drug is Cox-2 selective
Celecoxib
NSAIDs AE
GI (N/V, dyspepsia, ulcers, bleed), ↑ BP, nephrotoxicity, CV risk (variable)
Who should be careful when taking NSAIDs
history or GI bleeds, elderly, poor kidney function
Negative GI effects with Cox-1 inhibition
peptic ulcers
Negative Renal effects with Cox-1 and Cox-2 inhibition
Na and water retention
hypertension
acute kidney injury
Negative CV effects with Cox-1 and Cox-2 inhibition
if Cox-2>Cox-1 inhibition then it increases stroke and MI
How do you manage renal risk when taking NSAIDs/pain meds
monitor DDI, hydrate
How do you manage CV risk when taking NSAIDs/pain meds?
avoid celcoxib: naproxen (Aleve) generally consider safest
How do you manage GI risk when taking NSIDs?
celecoxib or ibuprofen is best; moderate risk may combine with PPI(protein pump inhibitors), or H2 blocker
other factors to reduce risk when taking NSAIDs
If very high risk – avoid NSAIDs if possible
Use topical if possible
Always lowest dose for shortest duration
Acetaminophen indications
analgesia, antipyretic, combo with NSAID to reduce NSAID dose and potential AE
Acetaminophen AE
hepatotoxicity (especially with alcohol and/or high doses)
Does Acetaminohen inhibit muscle repair
no
Which is safer to take in elderly patients? NSAIDs or acetaminophen?
acetaminophen
NSAIDs therapeutic concerns
GI bleed, increase risk for bleeding and bruising, hypertension, interaction between NSAIDs and cardiac medication (blunt action of CV drugs)
Kidney AE- Edema in the presence of CHF, interfere with diuretics
Suppression of cartilage repair
overdose in acetaminophen can happen when
hidden drugs that contain acetaminophen
what are the only FDA approved topical NSAIDs
diclofenac, Voltaren gel, Flector patch
OTC tropical NSAID
trolamine salicylate (Aspercreme)
Intraarticular hyaluronate recommendations
AE
Synvisc
recommend for knee and hip OA
AE- injection site pain, swelling, rash
List intraarticular steroids and how long does the effects last
Trimacinolone
metylprednisonlone (Depo-Medrol)
does not have immediate effect but can last for several months
Glucosamine AE
enhance antiplatelet effects so caution if high-bleed risk
Chondroitin bioavailability
and AE
large molecules make it poor bioavailability and too large to enter cartilage cells
exacerbate asthma and have antithrombotic effect
List non-biologic DMARD
Methotrexate, Sulfasalazine, Hydroxychloroquine
List biological DMARD (TNF-inhibitors and Non-TNF inhibitors)
TNF-inhibitors- Adalimumab (Humira), Etanercept (Enbrel)
Non-TNF inhibitors: Rituximab (Rituxan)
American college of Rheumatology guidelines
start DMARD immediately
if treatment fails, swtich to differnt med
Combine methotrexate with another DMARD can improve efficacy
Prednisone
Class
MOA
Corticosteroids
MOA: deccrease inflammation and suppress immune system
Prednisone Short-term AE and Long term AE
Short-term: increase blood glucose, mood changes, fluid retention
Long-term AE: osteoperosis, thin skin, muscle wasting, poor wound healing, adrenal suppression, Cushing disease, increase risk of infection
How do you reduce GI, hepatic and hematologic toxicity when prescribed Methotrexate
Take Folic acid
Methotrexate: Common and less common AE
Common AE: N/V/D
Less common AE- hepatotoxicity, nephrotoxicity, thrombocytopenia, bone marrow suppression
Methotrexate Box Warning
bone marrow suppression, increase risk of infection, various toxicities (GI, pulmonary, dermatological),
Hydroxychloroquine Common and Rare AE
Common AE: GI and skin reactions
Rare AE: retinal toxicity
hydroxychloroquine vs methotrexate
hydroxychloroquine is going to address symptoms while methotrexate address the progression
Common theme when box warning in Biologic DMARD
serious infection and secondary malignancies (lymphoma)
Common AE theme in Biological DMARD
antibody development and infection
another option if can have side effects with DMAR. what to take?
Janus kinase inhibitors because are smaller molecules and better absorbed and better bioavbility. has less side effects
Rehab concerns with DMARD
Skin rashes,
Renal effects- keep patient hydrated
Liver effects
Immunosuppression, bone marrow suppression, easily bruised, anemia, fatigue
DMARDS + High-dose steroids
Catabolic effect
careful with strengthening, stretching, deep tissue work
Cannabidiol
non-psychoactive component of marijuana
Medical Marijuana uses/evidence
reliving chronic pain
Antiemetic (effective against V/N)
reduced spasticity with MS
Role PT with CBD and medical Marijuana
be an educational resource
Monitor pain levels
be aware of signs of abuse
what are 4 phases in Anesthesia?
- Analgesia/Iduction
- Delirium/Disinhibition
- Surgical anesthesia
- Medullary paralysis
Analgesia/Induction
decrease awareness of pain, sometimes amnesia
Delirium/Disinhibition
loose conscious (delirious and excited) and changes/irregular in respiration, reflexes are enhanced
Surgical anesthesia
unconscious, no pain reflex, normal respiration, BP is maintained
medullary paralysis
never want to go to this phase, respiratory collapse. lead to death
goal for anesthesia
loss of consciousness, analgesia, amnesia, skeletal muscle relaxation, inhibition of sensory and autonomic reflexes
Hanover effect with anesthetics
happens during inhaled anesthetics. anesthesia stays longer when redisuptued in obese patients thus the effect is more pronounced
IV Anesthetics
used in combo with inhaled anesthetic
quick onset, quick recovery
often preferred for induction
Lidocaine
regional or local anesthesia
Regional Anesthesia in combo with?
general anesthesia to decrease doses
regional anesthesia can be administrated?
Intrathecal (route of administration for drugs via an injection into the spinal canal), epidural
Local anesthetics advantages/disadvantages
A: quick recovery, low toxicity, action confined to nerve tissue
D: incomplete analgesia, longer time to anesthesia
AE Local Anesthetics
CNS stimulation to CNS depression
CV: arrhythmia, bradycardia, hypotension, cardiac arrest
-respiratory depression
rehab concerns with anesthesia
prolonged drowsiness, fall risk, impaired airway clearance, suppress imune function
what can PT do to older adults with anesthesia?
have them use their incentive spirometer
postural drainage
beers list
List of potentially inappropriate meds in older adults
What opioids drugs contain acetaminophen?
Vicodin and Percocet
What is an opioid?
any substance whether endogenous or synthetic that produces morphine-like effect that are blocked by the morphine antagonist naloxone
Opioids indications
analgesia, antitussive (codine)
Opioids MOA
bind opioid receptors in the CNS to inhibit ascending pain pathways
Opioids common AE
nausea, constipation, drowsiness
Beers list for Opiods
in combo with >2 CNS active meds; if history of falls or fracture
Box warnings Opioids
increased levels with ethanol use, life-threatening respiratory depression
List of Strong μ-Agonists
Morphine (MS Contin) Fentanyl ( Duragesic) Hydromorphone (Dilaudid) Meperidine (Demerol) Methadone Oxycodone (Oxycontin; with acetaminophen: Percocet)
What do you watch for when taking Fentanyl?
do NOT use for chronic pain management if opioid naive; physical activity/heat on the patch ↑ drug delivery, properly dispose of patch
What drug is Mild-Moderate μ-Agonists
Codine
What drug opiod drug is a prodrug?
what is a prodrug?
Codine
When it enters the body it dosn have aneglisa. It has to go to the metabolism process. then codeine is converted to morphone to have an effect
Opioid Agonist-Antagonists
Indication- mild-moderate pain, opioid dependence
Buprenophine-
Agonist with high affinity μ-receptor but lower analgesic efficacy than other opioids
Antagonist at delta and kappa receptor
Tramadol
Weak μ- and κ-agonist AND inhibits reuptake of norepinephrine and serotonin (neurotransmitters in the descending inhibitory pain pathway) by increasing reuptake we are getting better pain control
Tramadol AE
Increases risk of seizures so avoid if personal history or in combo with other drugs that could increase risk (ex: some antidepressants such as SSRI)
Dosing for opioids
use morphine equivalents
- based on receptor activity
- differs base on route
CNS effects with opioids
Sedation Respiratory depression Cough suppression Miosis- pinpoint pupils Truncal rigidity Vomiting
Peripheral effects
Constipation Urinary retention Bronchospasm Reduced GI motility Pruritus- itchy skin
Gastric emptying in opiods
delay gastric emptying thus impacting absorption of other drugs thus increase DDI
what happens to the Respiratory system when taking opioids?
respiratory depression; avoid if baseline respiratory disease
How do you treat overdose?
Opioid Antagonist
naloxone (Narcan)
Competitive antagonist at μ-, κ-, and δ-receptors
Highest affinity for the μ-receptor = rapidly reversing respiratory depression and euphoria
Who should have naloxone?
Those with legitimate prescriptions for high doses of opioids, especially if also taking benzodiazepines, using alcohol or with some concomitant disease states
Those illegally abusing opioids
Family members and friends of the above
Opioids therapeutic concerns
increase fall risk
patches- avoid heat and exercise in area of of patch
Drowsiness, dulled cognition, constipation
Be aware patient’s pain perception will be altered- wait 30-40 min after
stimulus independent
shooting, shock-like, aching, burning pain
1st line treatment for neuropatic pain
Gabapentin
Acute treatment for neropatic pain
Tramadol
Gabapentin AE
commonly prescribed due to?
dizziness, drowsiness
Cost
When handling capsaicin cream
never apply to broken skin and always wash your hands
Chronic opioids start with
bowel regimen (stool softener, laxative)
Cancer bone pain
is difficult to treat and require high opioid doses
add bisphosphnate
drugs class to treat OA?
acetaminophen NSAID (topical, oral) Intraarticular hyaluronate Intraarticular steroids Glucosamine-Chondroitin (Not recommended)
Synvisc drug class?
MOA?
Intraarticular hyaluronate
Joint lubrication
list Intraarticular steroids drugs?
Trimacinolone
methylprednisolone (Depo-Medrol)
How long do Intraarticular steroids last?
Does not have an immediate effect but can last for several months (max: 4 injections/year)
Drug class to treat RA?
Non-Biologic DMARD Biologic DMARD Corticosteroids NSAIDs to reduce pain and swelling Opioids- pain relief
