Pharm

Question 1

How does DA affect the basal ganglia pathways?

Answer 1

activates direct pathway by binding to D1 receptors in striatum
inhibits indirect pathway by binding D2 receptors in striatum

Question 2

What is the major degeneration in Huntington’s?

Answer 2

GABAergic inhibitory neurons –> hyperkinetic

Question 3

What percentage of nigrostriatal dopaminergic neurons are lost before the symptoms of PD? What does this mean for drugs?

Answer 3

70-80%, most antipsychotics fxn when 70% D2 receptors blocked –> why they cause Parkinson symptoms

Question 4

What is the difference between acute pain and chronic pain?

Answer 4

acute - from tissue trauma and inflammation, serves protective role, gone when injury heals = adaptive because promotes healing by restricting use of damaged areas
chronic - >3-6 mos, maladaptive

Question 5

How is neuropathic pain different than nociceptive?

Answer 5

from direct injury to nerves, not activation of nociceptors

Question 6

What are some important features of nociceptive pain and how it is managed?

Answer 6

somatic easy to localize, visceral is harder
tissue injury usually apparent
opiates most often relieve but may need adjuvants

Question 7

When are adjuvant meds most helpful?

Answer 7

neuropathic, bone, smooth muscle, or skeletal muscle pain
increased ICP pain
when pt drowsy but still in pain!

Question 8

How is neuropathic pain generally managed?

Answer 8

relieved somewhat with opiates, often needs adjuvants

Question 9

What are characteristics of bone pain?

Answer 9

pain in bony tissue, achy, deep
worse with movement
often well localized

Question 10

What kinds of meds are used to treat bone pain?

Answer 10

NSAIDs, Cox2 inhibitors
steroids
radiation therapy
calcitonin
bisphosphonates
opiates
radiopharmaceuticals

Question 11

What are characteristics of smooth muscle spasm pain?

Answer 11

intermittent, severe, sporadic, come and go pain

worsens with opiates

Question 12

What kinds of meds are used to treat smooth muscle spasm pain?

Answer 12

anticholinergic/antispasmotic agents: hyoscyamine, dicyclomine, atropine, scopolamine

Question 13

What are characteristics of skeletal muscle spasm pain?

Answer 13

voluntary muscle injury or neurons misfiring
worse w movement/change of position
pts may assume unusual postures to relieve

Question 14

What kinds of meds are used to treat skeletal muscle spasm pain?

Answer 14

physical measures - ice, heat, etc.

meds = muscle relaxants = baclofen, benzodiazepenes, methocarbamol, cyclobenzaprine

Question 15

How is increased ICP pain treated?

Answer 15

steroids = dexamethasone, methylprednisolone

consider seizure prophylaxis

Question 16

What is the WHO pain ladder?

Answer 16

step 1: mild pain - non-opiates (acetaminophen/NSAIDs/aspirin), maybe adjuvants
step 2: moderate pain - opiate/acetaminophen combo drugs, maybe adjuvants, ceiling dose 4 g tyl/day, consider tramodol or vicoprofen
step 3: severe pain - opiates, but demerol not recommended

Question 17

What is one visceral pain that actually improves w anti-inflammatory treatment?

Answer 17

capsular stretch pain - stretching of liver capsule due to tumor,cirrhosis, or hepatomegaly

Question 18

How are equianalgesic doses used to switch between analgesics?

Answer 18

start new med at 50-75% of equianalgesic dose and go from there

Question 19

What are some principles of dosing opiates?

Answer 19

individualize by gradually escalating dose
around-the-clock dosing for continuous or frequently recurring pain
PRN dosing should be available for breakthrough pain (rescue dosing)

Question 20

How can you select long acting vs. short acting opioids?

Answer 20

if requiring meds every 4 hrs PRN, consider long acting

consider patient factors

Question 21

When are IV/SQ options considered sooner in pain management?

Answer 21

losing oral route, high cost of med/day, pediatric compliance with po dosing

Question 22

What are some important advantages/disadvantages of morphine, oxycodone, hydromorphone, fentanyl, methadone?

Answer 22

morphine: long acting is PR, no ceiling, easy to titrate, some stigma
oxy: more potent long acting but more euphoria, can’t give rectally
hydromorphone: when morphine is problem, safe in liver patients
fentanyl: less constipating, less stigma, hard to titrate, conversions vary, skin issues, cost issues
methadone: cheap, highly effective, long duration, more serious side effects - get EKG

Question 23

How should rescue dosing be given?

Answer 23

breakthrough dosing should be 10-20% of total daily opiate equivalent
frequency if oral is every 1-2 hrs
frequency if IV is every 10-30 min
total amount of required breakthrough in 24 hrs divided by 2 and added to pt’s 12 hr opiate dose

Question 24

What are the principles of opioid dose adjustment?

Answer 24

no ceiling of opioid except toxicity so doses can be large - watch for side effects
increase dose by 25-50% for mild-mod pain
increase dose by 50-100% for severe pain
increase rescue dose as baseline is increased

Question 25

What is tolerance?

Answer 25

physiological phenomenon - the change in dose-response induced by exposure to drug and manifested by need for increased dose over time
increased requirement after STABLE management may indicate dz progression, not tolerance

Question 26

What is dependence?

Answer 26

physical phenomenon - withdrawal syndrome can occur following abrupt cessation or decrease of analgesic med or admin of an antagonist - can avoid with tapering
does NOT equal addiction

Question 27

What is addiction?

Answer 27

psychological and social syndrome - compulsion to seek and take drugs for other than their therapeutic effects
uncommon, usually just pseudoaddiction from improper management

Question 28

What are the most common SEs seen w opioids and how long do they last?

Answer 28

drowsiness, nausea/vomiting, constipation, itching
most will extinct over 5-7 days
if pt near death, may be better to treat SE than switch medication

Question 29

What are the general principles of managing constipation?

Answer 29

dietary: increased fluid intake, prunes, yogurts or probiotics, fruit paste, yogurts, fiber products if younger
pharm: laxatives, stool softeners, osmotic agents if pt hydrated
enema if impaction (failed prophylaxis) - give pain meds

Question 30

What are the principles of lethargy/sedation as a side effect of opioid use?

Answer 30

dev in first 24 hrs - should resolve in 24-48

can use psychostimulants (methylphenidate) to combat unavoidable lethargy

Question 31

What is the management of persistent opiate-induced sedation/cognitive impairment?

Answer 31

stop non essential centrally acting meds
evaluate and treat other potential causes (inf?)
if pain relief ok decrease opiate dose by 25%
if pain relief poor or sx persist despite reduction - add stimulant or rotate opioid

Question 32

What is the management of hallucinations/confusion as a SE of opioids?

Answer 32

decrease dose or change to another one rapidly

if not possible, give antipsychotics

Question 33

How can myoclonus be managed as a SE of opioids?

Answer 33

opioid rotation, decrease dose, addition of low dose benzodiazepine

Question 34

What are the two major categories of glaucoma?

Answer 34

acute congestive - narrow (closed) angle: closure of angle between iris and corneal endothelium blocks aqueous flow, usually induced by mydriasis
chronic simple - open angle: flow is reduced for unknown reasons, gradual onset, more common

Question 35

What are the differences between dry and wet AMD?

Answer 35

dry - non-neovascular, slow loss in central vision, appearance of drusens, no specific treatment
wet - neovascular, rapid decline in central vision, proliferation of leaky blood vessels, treatments