pain (rogers) pt 2 Flashcards
step 1: non-opioid analgesics
non-opioids (2)
adjucant therapies (6)
gabapentinoids
gabapentin (Neurontin) and pregabalin (Lyrica)
uses
- fibromyalgia
- ___
- post-operative pain
available formulations
- tablets/capsule
- ER tablet
- liquid solution
recommended dosing
- gabapentin (Neurontin): ___ - ___ mg PO ___ (max ___ mg/day)
- pregabalin (Lyrica): ___ mg PO ___ (max ___ mg/day)
SE
- ___ , dizziness, peripheral edema
clinical pearls
- ___ dose adjusted
- titrate up dose to limit ___
- use in combination to decrease requirements of other analgesics
- pregabalin is a schedule V controlled substance, gabapentin is unscheduled
- neuropathies
- 100-300, TID, 3600
- 75, BID, 600
- sedation
- renally
- sedation
SNRIs
venlafaxine (Effexor) and duoxetine (Cymbalta)
uses
- fibromyalgia
- ___
available formulations
- capsule/tablet
- ER capsule/ER tablet
recommended dosing
- venlafaxine: ___ - ___ mg PO daily (max ___ mg/day)
- duloxetine: ___ mg PO daily x 1 week, then increase to __ mg PO daily (max ___ mg/day)
SE
- ___ , headache, ___ , sedation, weakness
clinical pearls
- start low dose and titrate up to minimize side effects
- renally dose adjust venlafaxine and avoild duloxetine for CrCl < ___ mL/min
- neuropathies
- 37.5-75, 225
- 30, 60, 60
- nausea, HTN
- 30
TCA’s
uses (all off label)
- fibromyalgia
- ___
- ___ prophylaxis
available formulations
- tablet ( ___ )
- capsule ( ___ )
- oral solution ( ___ )
recommended dosing
- amitriptyline or nortriptyline: ___ mg PO QHS (max ___ mg/days)
SE
- ___ SE, sedation
Clinical pearls
- ___ line option for neuropathy and fibromyalgia due to side effects
- neuropathies, migraine
- amitriptyline, nortriptyline, nortriptyline
- 10, 150
- anti-cholinergic
- last
muscle relaxants
- ___ (Amrix, Fexmid)
- ___ (Lioresal)
- ___ (Robaxin)
- ___ (Soma)
- ___ (Zanaflex)
uses
- musculo-skeletal pain/spasms
available formulations
- tablet/capsule (IR/XR)
- oral suspension ( ___ )
- parenteral solution ( ___ and ___ )
recommended dosing
- cyclobenzaprine ___ mg PO TID (max ___ mg/day)
- baclofen ___ mg PO TID (max ___ mg/day)
- carisoprodol ___ - ___ PO TID (max ___ mg/day)
- methocarbamol ___ g PO 3-4x/day (max __ g/day)
- tizanidine __ - __ mg PO q8-12h (max ___ mg/day)
SE
- ___ /drowsiness, dizziness, dry mouth, ___ changes
clinical pearls
- short term use ( < __ weeks)
- carisoprodol is schedule ___ due to abuse potential
- cyclobenzaprine, baclofen, methocarbamol, carisoprodol, tizanidine, baclofen
- baclofen, methocarbamol
- 5, 30
- 5, 80
- 250-350, 1050
- 1.5, 8
- 2-4, 24
- sedation, vision
- 3
- IV
antiepileptics - carbamazepine (Tegretol)
uses
- ___ pain
available formulations
- tablet, ER capsule/tablet, chewable tablet, suspension
recommended dosing
- ___ - ___ mg PO daily in 2-4 divided doses (max ___ mg/day)
clinical pearls
- increased risk of ___ reaction in patients with ___ allele
- ___ of hepatic enzymes (levels will fall over first few weeks of use)
- neuropathic
- 200-400, 1200
- hypersensitivity, HLA-B*1502
- autoinduction
topical agents: lidocaine
available formulations
- patch (4% OTC, 5% Rx)
- injection
- topical
recommended dosing
- apply 1 patch to affect area daily and remove __ hours later (can vary by manufacturer)
SE
- ___ , arrythmia (minimal risk with ___ )
clinical pearls
- ___ with continuous use
- ___ hour break between patchs
- local effect - apply to site of pain
- 12
- hypotension, patch
- tachyphylaxis
- 12
topical agents: capsacian
uses:
- muscle/joint pain
- neuropathic pain
available formulations
- cream, gel, liquid, lotion: apply __ - __ times per day
- patch: apply 1 patch to affected area daily and remove ___ hours later
SE
- skin irritation and pain
clinical pearls
- do not get medicine into eyes
- wash hands after applying
- OTC
- 3-4
- 8
geriatric considerations
non-COX-2 selectice NSAIDs, oral (including ASA > 325 mg/day_
- avoid ___ use
- avoid __ term use in combo with oral or parenteral ___ , anticoagulants, or ___ agents
- if no other option add a GI protective agent such as a ___ or ___
rationale
- increased GI ___ or peptic ___ disease
- also can increase ___ and induce ___ injury (risks are dose related
- chronix
- short, corticosteroids. antiplatelet
- PPI, misoprostol
- bleeding, ulcer
- BP, kidney
geriatric considerations
indomethacin and ketorolac
recommendation: ___
rationale:
- increased risk of GI ___ , peptic ___ disease, and acute ___ injury
- of all the NSAIDs, ___ has the mose AE, includng higher risk of ___ effects
AVOID
- bleeding, ulcer, kidney, indomethacin, CNS
geriatric considerations
skeletal muscle relaxants (carisoprodol, cyclobenzaprin, methocarbamol)
recommendation: ___
rationale
- poorly tolerated by older adults due to ___ SE, ___ , and increased risk of ___
- effectiveness at tolerable doses is questionable
- this does not include ___ or ___ , although these can also cause substantial AE
AVOID
- anti-cholinergic, sedation, fracture
- baclofen, tizanidine
geriatric considerations
SNRIs, TCAs, carbamazepine
recommendation: use with ___
rationale:
- may exacerbate or cause ___ or ___
- monitor ___ levels closely when starting or changing dosages in older adults
caution
- SIADH, hyponatremia
- Na
geriatric considerations
combo of meds: opioids and BZDs
recommendation: ___
rationale
- increased risk of ___ and AE
AVOID
overdose
geriatric considerations
opioids and gabapentin/pregabalin
recommendation: ___
exceptions:
- ___ from opioid to gabapentinoid
- using gabapentinoid to ___ opioid dose
rationale
- increased risk of severe sedation-related AE like ___ depression and death
- AVOID
- transitioning
- reduce
- repiratory
geriatric considerations
combo: 2 anticholinergics
- example TCA or muscle relaxant and another anticholinergic med
recommendation - ___
- minimize the number of anticholinergic drugs
rationale
- increased risk of ___ decline, delirium, and falls or fractures
- AVOID
- cognitive
d/c (taper?) duloxetine
Options
* increase dose/frequency of APAP
* Gabapentin and renally adjust
* venlafaxine (renal adjustment) - good if pt had depression that was also being treated with the duloxetine
SE of venlafaxine
* sedation, HA, N/V
opioid agonists/antagonists
antagonist (1)
weak agonist (2)
full agonist (7)
