Pharm- Antihistamines and Pain Flashcards
1st generation ORAL Antihistamines
Benadryl (diphenhydramine)
Dramamine (dimehydrinate)
Phenergan (Promethazine)
Antivert (Meclizine)
Hydroxyzine (Atarax, Vistaril)
1st generation that is VERY sedating, good to use if pt’s sx are keeping them up at night (like so itchy)
Hydroxyzine
2nd generation ORAL Anthistamine (less SE overall, not as sedating)
Claritin (Loratadine)
Zyrtec (Cetirizine)
Allegra (Fexofenadine)
out of the 2nd generation, which one is the most sedating?
Zyrtec (Cetirizine)
Nasal and Ocular Antihistamines
Azelastine
Azelastine + Fluticasone
Antihistamine SE
just like Anticholinergic
Red as beet Dry as bone Blind as bat Mad as hatter Hot as hare
1st line for Allergic Rhinitis:
Inhaled Nasal Steroid
Flonase (Fluticasone) nasal spray
Approved Antihistamines for jobs where worker CANNOT be sleepy
Claritin (Loratadine)
Allegra (Fexofenadine)
If pilot takes a non-approved Anti-histamine, how long until they can fly?
5 times the drugs 1/2 life
Flomax (Tamsulosin) is
a-blocker
Used to tx BPH
What meds should NOT be used along with Flomax (Tamsulosin), an a-blocker
Sudafed
Benadryl (Diphenhydramine)
Bc ALL OF THESE can cause Urinary Retention
What are the classes you should avoid due to BPH
Decongestants
1st Gen Antihistamines
reason: can trigger urinary retention
What about a person with GLAUCOMA that has seasonal allergies?
Decongestant
Antihistamine
Steroids
ALL can increase IOP, so
Speak with pt’s eye doctor
Can follow IOP closely, consider immunotherapy
Scabies treatment
Permethrin cream
If someone has itchy sx, what can help them sleep?
Hydroxyzine (atarax)
Benadryl (diphenhydramine)
Chronic urticaria, sometimes linked to Auto-Immune condition
Tx with Non-sedating Antihistamine (2nd gen)
Poison Ivy tx
Steroid cream
Non-sedating Antihistamine (2nd gen)
Steroid cream for poison ivy
Triamcinolone (Kenalog) cream
What is Augmentin?
Amoxicillin/Clavulanic acid
has Penicillin in it, cannot give Augmentin to someone with PCN allergy
If person has hives,
Has tried Steroid and Anti-histamine and STILL NOT IMPROVING
can add H-2 blocker as adjunct
not 1st line
3 meds to immediately get on hand to treat Anaphylaxis
Benadryl
Epi
Steroid
Definition of Anaphylaxis
Affects >1 body part at same time
Skin/mucosa: 90%
Respiratory: 70%
GI: 45%
Cardiac: 45%
An example of what to give someone experiencing Anaphylaxis
Benadryl
EPI
Steroid: Dexamethasone aka “Decadron”
H-2 blocker as adjunct: Famotidine (pepcid)
Consider these ppl HIGH RISK when Rxing ANTIHISTAMINES and be very careful
BPH
Glaucoma
Very young/very old
High risk jobs
Short acting Opioids
Ultram (tramadol) Nucynta Norco Percocet Opana Diluadid
Short acting Opioids used in CA pain only
Actiq, Subsys, Abstral
AKA FENTANYL
much shorter half life
Norco is
Hydrocodone + Tylenol
Percocet is
Oxycodone + Tylenol
Long acting opioids will have “ER at the end; extended release” in Generic name,
Or Brand name is:
Oxycontin
Dilaudid
Methadone
Not as common
Very potent, cheap
Good for: Neuropathic pain
Generic name examples of Long acting pain med
Oxycodone ER Oxymorphone ER Morphine Sulfate ER Hydromorphone ER Fentanyl patch
Pseudo- addiction
Undertreated pain resulting in red flag behaviors
but pt is really in pain
Nociceptive pain
“typical pain”
Injury to tissues
peripheral pain receptors
Laceration Fracture Post op surgery Tumor/CA Internal organ injury
Options to tx Nociceptive pain
NSAIDs Tylenol Steroids Opioids PCA-pt controlled analgesics Physical Therapy TENs unit Muscle relaxant
Neuropathic pain
Dysfx of Nerves, Spinal cord, or Brain
Examples of Etiology of Neuropathic pain
Post herpes Radiculopathy Trigeminal neuralgia Diabetic neuropathy Phantom lib CVA, Traumatic spinal cord injury
Meds that help with Neuropathic pain
Neurontin (gabapentin) Lyrica (pregabalin) TCA Duloxetine (cymbalta) Tramadol Nucynta Lidoderm patch
ESI (epidural steroid injeciton)
Firefighter with back pain
NSAIDs Muscle relax Trigger point injection in office Medrol dose pack Ice/heat Consider short course of Opioids
F/u in 1-2 weeks
If no improvement of back pain
Consider PT, imaging, repeat Trigger point injection if it helped
TENs unit
Older gardener lady with RA, on Percocet 10/325 every 6 hours but the 1/2 life of this is only 3-4 hours… she is a compliant pt… what can we do?
Consider switching to Long Acting Opioid:
Oxycontin ER q12 hrs
If switching from Short to Long acting Opioid, what do we need to consider?
Reduce daily dose by 50-75% when converting
Consider low dose opioid for breakthrough pain while converting
Breakthrough med no more than 25% of daily acting long dose
What can we add topical for joint pain?
Topical compound cream, i.e.:
Lidocaine
Ibuprofen
Diclofenac
Meds for Diabetic Neuropathy and
Fibromyalgia
Gabapentin (neurontin)
Pregabalin (lyrica)
Cymbalta (duloxetine)
Pt Controlled Analgesia a good option for
intractable CA pain
Considerations when using PCA (patient controlled analgesia)
Order continuous Pulse ox
Narcan orders
Monitor Mental status, Respiratory status
Doc/PA see pt again within 12 hours
Once dose stable, see every 12-24 hrs
PO to IV morphine conversion is typically 3:1
soo if pt is on IV and wants to go to Oral
have to multiple dose x 3
20mg IV qd x3 = 60 mg Morphine qd
Fentanyl patch
NOT GREAT for acute pain
Better for long term, takes 12 hours to reach therap levels
Fentanyl additional considerations
less effective in super skinny pts (cachectic)
exposure to heat increases potency- increased absorption- can be fatal!
Methadone
Cheap, potent, good for NEUROPATHIC pain
CAUTION:
QT prolongation (tDP risk) many drug interactions
Tramadol/Nucynta
good for NEUROPATHIC pain
CAUTION:
pts on Antidepressants–> Seretonin syndrome
Drug of choice in ESRD (end stage Renal dz)
person has bad Kidney
Fentanyl
Methadone
If pt has Hepatic dz (bad liver)
Avoid Opioids
Increased Intracranial pressure
NO opioids
Considerations for Rx of Opioids
Write out in LONG hand the # of pills
Wong-Baker FACES pain rating scale
3YO and older
look at faces and match pain scale
Behavioral observation Pain scale
Scores:
- facial expression
- able to be consoled
- level of interaction
- limb/trunk motor responses
- verbal responses
FLACC pain score
Face Legs Activity Cry Consolability
Opioid analgesics commonly used in kids
Morphine Hydromorphone Oxycodone Hydrocodone Fentanyl Methadone
When to refer
Current interventions not working
Chronic pain
PCA-pt controlled analgesia
Life-limiting condition
If parent gave something at home that was working, and pt hasn’t had the most recent dose
give that SAME med in office
if it was working, use it again
Testicular torsion
No cremasteric reflex-testicle does not rise when thigh is stroked
Steps to tx testicular torsion
Manual detorsion
Surgical detorsion
Pain med
Nausea med
Appendicitis
Opioids are indicated as pre-op
need to be IV bc this pt is now NPO
12 YO w burn to hand, abdomen, and left leg
15% total
need to refer her bc >10% AND involving her HAND
following ABA referral criteria
What do we want to avoid in peds opioids
NO Codeine or Tramadol in 12 or younger
<12 yo
NO Codeine or Tramadol
Ginkgo biloba should not be used with ____ in elderly
Warfarin
*inc risk of bleeding
St. John’s Wort should not be used with _____
SSRI
*inc risk of Serotonin Syndrome
Age related changes to consider with aging
Inc body fat relative to muscle
Natural decline in Kidney fx
Declining Liver fx
(rapid weight loss can lead to increased absorption of med)
BEERS criteria
Avoid using Opioids with BENZOS or GABApentinoinds
Opioids with Benzos can lead to
severe ADE- adverse drug events like Respiratory depression, death
Avoid use of SNRI
pt with hx of Falls or Fractures
STOPP criteria (Screening Tool of Older Person’s Prescriptions)
Consider drug intxns
Duplications of drugs within a class
Older pt with joint pain, already on Diazepam
“pam” is a Benzo!!
DON’T want to add Opioid
bc Opioid + Benzo is a no-no
Opioid naive 70 YO pt with compression fracture, severe low back pain
Can give short acting opioid, 3 day follow up
