Pain & TNF alpha inhibitors

Question 1

Which considerations needs to be considered before taking a TNF alpha inhibitor

Answer 1

scan for latent or active infections: TB, HEP B &C, HIV, hold therapy if active infection, complete all live vaccines if needed, assess for malignancy risk, assess for HF, consider neurologic history (MS), baseline labs CBC, LFT, renal panel

Question 2

Which types of vaccines are allowed in someone taking TNF alpha inhibitor or which are not recommended for patient taking TNF inhibitor

Answer 2

Allowed: inactivated ( flu, hep A&B, polio), TDAP, HPV, pneumococcal, meningococcal, covid, shingrix
Contraindicated: MMR, varicella, zoster, live intranasal flu, rotavirus

Question 3

Common side effects to educate patients if diabetic and on oral steroids

Answer 3

Hyperglycemia which can cause increased thirst and urination, blurred vision and fatigue. Temporary adjustment of insulin or oral anti diabetic med may be required, monitor blood sugar more frequently

Question 4

Which enzyme is responsible for GI side effects of NSAIDs

Answer 4

Cyclooxyrgenase-1 (COX-1)

Question 5

Patient education for topical steroid use

Answer 5

-absorption is dependent on thickness of skin, occlusive dressing absorbs more readily, avoid facial application> atrophy (thin transparent skin/nonreversible), keep away from eyes

Question 6

Why NSAIDs have negative effect on kidneys

Answer 6

Inhibit COX enzymes which decreases prostaglandin synthesis this can lead to decreased blood flow to kidneys/AKI

Question 7

What best treatment for reticular or neuropathic pain is

Answer 7

• gabapentin, pregabalin (Lyrica)

Question 8

Which analgesic has potential for serotonin syndrome

Answer 8

*Tramadol is a centrally acting synthetic opioid.
* It has dual action:
1. Weak mu-opioid receptor agonist
2. Inhibits reuptake of serotonin and norepinephrine (SNRI-like)

Question 9

MOA of toradol

Answer 9

*Nonselective inhibition of cyclooxygenase (COX-1 and COX-2) enzymes
*↓ Synthesis of prostaglandins, which are mediators of:
*Pain
*Inflammation
*Fever

Question 10

Indications of use for Lyrica:

Answer 10

neuropathic pain and sleep/anxiety improvement
FDA indications: diabetic peripheral neuropathy, postherpetic neuralgia, fibromyalgia, neuropathic pain post spinal cord injury, adjunct with other anticonvulsants for seizures