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Ahmed Neuro 2 Depression > Pharm - Pain > Flashcards

Pharm - Pain Flashcards

1
Q

describe nociceptive pain

  • what is somatic pain
  • what is visceral pain
A

perception of input from a nocicpetor, a nerve fiber preferentially sensitive to noxious stimulus

somatic: arises from injury to body tissues, well localized
visceral: arises from viscera stretch receptors, poorly localized

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2
Q

describe neuropathic pain

  • what is sympathetically mediated pain
  • what is peripheral neuropathic pain
  • what is central pain
A

arises from abnormal neural activity secondary to dz/injury/dysfunction of the nervous system

sympathetically mediated: arises from peripheral nerve lesion and associated w/ autonomic change

peripheral neuropathic: due to damage to a peripheral nerve W/O autonomic change

central pain: arises from abnormal CNS activity

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3
Q

compare mononeuropathy, mononeuropathy multiplex, and polyneuropathy

A

mononeuropathy: one nerve affected

mononeuropathy multiplex: several nerves affected in different areas

polyneuropathy: sx are diffuse and bilateral

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4
Q

what are the two types of pain sensation

A

1) tissue damage –> release of local inflammatory mediators –> hyperalgesia (exagerrated response to pain)/allodynia (pain from repeated exposure)
2) gluatamate stimulation of spinal NMDA receptors —> secondary hyperalgesia

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5
Q

what do these abbreviations stand for

  • AA
  • coxibs
  • PG
  • PGI2
  • PUFA
  • TxA2
A
  • AA: arachidonic acid
  • coxibs: selective inhibitors of cox-2
  • PG: prostaglandin
  • PGI2: prostacylin
  • PUFA: polyunsaturated fatty acid
  • TxA2: thromboxane A2
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6
Q

describe the arachidonic acid pathway

A

arachidonic acid –> COX –> PGI2, TXA2, PGD2, PGE2

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7
Q

what are the effects of thromboxane A2 (produced in the arachidonic acid pathway)

A

vasoconstriction

increased platelet aggregation (thrombotic)

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8
Q

what are the effects of prostacyclin (produced in the arachidonic acid pathway)

A

vasodilation

decreased platelet aggregation (anti-thrombotic)

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9
Q

what are the effects of PGE2 (produced in the arachidonic acid pathway)

A

joints: swelling, pain, edema

gastric mucosa: gastric protection

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10
Q

compare COX 1 and 2

A

both use AA, both make PGs, both have physiological role in renal function

COX1:
constitutive expression, all tissue all the time, responds to PHYSIOLOGICAL stimuli, contributes to response to pathological stimuli that release AA

COX2:
some tissues some times, prominent role in response to PATHOLOGICAL stimuli that release AA

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11
Q

when NSAID therapy is required for a patient at risk of CV complications, _______ is recommended as the NSAID of choice

A

naproxen

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12
Q

what are come contraindications for NSAID use

A

1) chronic kidney disease w/ creatinine clearance <60
2) active duodenal or gastric ulcer
3) CV dz
4) NSAID allergy
5) ongoing tx with anticoags (warfarin)

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13
Q

4 major actions of aspirin

A

1) suppression of inflammation
2) relief of mild–>moderate pain
3) reduction of fever
4) prevention of MI and stroke

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14
Q

MOA aspirin

A

irreversible Inhibition of COX

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15
Q

common indications for aspirin

A
  • rheumatoid arthritis
  • chronic inflammatory conditions
  • post-operative pain
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16
Q

adverse effects of aspirin can occur in what patients

A
  • advanced age
  • pre-existing renal function
  • hypovolemia
  • HTN
  • hepatic cirrhosis
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17
Q

long-term aspirin use may lead to ______ and other forms of renal injury

A

renal papillary necrosis

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18
Q

why should aspirin not be used in children with chicken pox or influenza?

A

due to reye syndrome

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19
Q

effect of using aspirin during labor and elivery

A
  • can suppress spontaneous uterine contractions
  • can induce premature closure of ductus arteriosus
  • can intensity uterine bleeding
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20
Q

compare non-aspirin NSAIDs vs aspirin

A

both:

  • inhibit COX 1 and COX2
  • suppress inflammation, pain, and fever
  • increase risk of

non-aspirin NSAIDs:

  • reversible
  • suppress platelet aggregation but increase risk of MI and stroke
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21
Q

indications ketorolac

who cannot take it

A

short term (<5 days) management of moderately severe acute pain that requires analgesia at the opioid level

  • usually post-operative state

NOT indicated in peds patients, or for minor or chronic conditions

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22
Q

warnings for ketorolac

A

can cause peptic ulcers,GIbleeding and/or perforation of the stomach or intestines, which can be fatal

  • risk of bleeding
  • CV thrombotic events
  • renal risk
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23
Q

indications for indomethacin

A
  • Moderate to severe rheumatoid arthritis including acute flares of chronic disease
  • Moderate to severe ankylosing spondylitis
  • Moderate to severe osteoarthritis
  • Acute painful shoulder (bursitis and/or tendinitis)
  • Acute gouty arthritis
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24
Q

indomethacin is contraindicated in the treatment of _____

A

peri-operative pain in the setting of CABG surgery

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25
Q

contraindications ibuprofen

A
  • Active gastric or duodenal ulcer, a history of recurrent ulceration, gastrointestinal bleeding, or active inflammatory disease of the gastrointestinal system
  • Significant hepatic impairment or active liver disease
  • Severely impaired or deteriorating renal function
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26
Q

warning and precautions ibuprofen (what pts should not take it)

A
  • Patients with heart disease and high blood pressure
  • patients with heart failure, hypertension or other conditions predisposing to fluid retention
  • patients w/ gastrointestinal tract irritation, history of peptic ulcer, diverticulosis or other inflammatory disease of the gastrointestinal tract such as ulcerative colitis and Crohn’s disease
  • Increased risk of renal toxicity
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27
Q

adverse effects ibuprofen

A
  • decreased appetite
  • edema
  • fluid retention
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28
Q

indications flurbiprofen

A

sterile, topical produce for ophthalmic use for inhibition of intraoperative miosis

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29
Q

MOA flurbiprofen

A

COX inhibition

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30
Q

precautions flurbiprofen

A

may slow or delay healing

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31
Q

indications meloxicam

A
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Juvenile Rheumatoid Arthritis (JRA) in patients 2 years of age or older
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32
Q

contraindications meloxicam

A
  • History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs
  • In the setting of CABG surgery
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33
Q

warnings and precautions meloxicam

A
  • Hepatotoxicity
  • HTN
  • HF, Edema
  • Renal Toxicity
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34
Q

adverse reactions meloxicam

A
  • diarrhea
  • upper respiratory tract infections
  • dyspepsia
  • influenza-like symptoms
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35
Q

indications naproxen

A
  • RA
  • osteoarthritis
  • ankylosing spondylitis
  • polyarticular juvenile idiopathic arthritis
  • tendonitis, bursitis
  • acute gout
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36
Q

contraindications naproxen

A
  • History of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs

• In the setting of CABG surgery

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37
Q

warnings/precautions naproxen

A
  • Hepatotoxicity
  • CVR effects, HF, Thrombotic effects (BBW) and Edema
  • Can significantly compromise renal function in geriatric patients
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38
Q

black box warning for naproxen

A

thrombotic effects can occur with use

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39
Q

adverse rxn naproxen

A
  • Dyspepsia, abdominal pain, nausea
  • headache
  • rash, ecchymosis, and edema
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40
Q

indications diclofenac

A
  • Ankylosing spondylitis
  • Dysmenorrhea
  • Migraine
  • Osteoarthritis Pain
  • Rheumatoid arthritis
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41
Q

contraindications diclofenac

A
  • CABG surgery

- pts w/ moderate to severe renal impairment

42
Q

warnings/precautions diclofenac

A

increased risk of serious cardiovascular thrombotic events, including myocardial infarction (MI) and stroke, which can be fatal

this risk may occur early in treatment and may increase with duration of use. (BBW)

43
Q

adverse effects diclofenac

A
  • CV: edema, CV accident, HTN, MI
  • CNS: HA, dizziness
  • skin: pruritis, rash, stevens-johnson syndrome, toxic epidermal necrolysis
  • endocrine/metabolic: fluid retention
  • GI: constipation, abd pain, dairrhea
44
Q

MOA celecoxib

A

selectively blocks COX-2

45
Q

compare risks between celecoxib (selective COX2 inhibitor) and the non-selective cox inhibitors (COX 1 and 2)

A

celecoxib:

  • causes less gastric ulceration
  • does not inhibit platelet aggregation (no risk of bleeding)
  • increased risk of MI and stroke
46
Q

indications acetominophen

A

inhibition of prostaglandin synthesis in CNS

suppressed pain and fever but NOT inflammation

47
Q

compare adverse effects b/w acetominophen and NSAIDs

A
  • does NOT cause GI ulceration
  • does NOT suppress platelet aggregation
  • does NOT impair renal function
48
Q

acetominophen overdose is treated with _______

A

acetylcysteine

49
Q

why is using acetominophen with warfarin contraindicated

A

acetominophen inhibits metabolism of warfarin and can increase the risk of bleeding with its use

50
Q

why are antidepressants (TCAs) used to treat pain

A

they have independent analgesic effects as well as an ability to relieve the depressive sx associated with chronic pain

51
Q

what is the most widely studied TCA for chronic pain

A

amitriptyline

52
Q

what anti-depressants are used to treat neuropathic pain

A
  • duloxetine
  • venlafaxine

(both SNRIs)

53
Q

indications duloxetine (in terms of pain management)

A
  • chronic MSK pain
  • fibromyalgia
  • diabetic peripheral neuropathic pain
54
Q

contraindications duloxetine

A
  • Use of a MOAI concomitantly or in close temporal proximity

- Not used in patients with uncontrolled narrow-angle glaucoma

55
Q

warning duloxetine

A
  • Suicidality: Monitor for clinical worsening and suicide risk
  • Hepatotoxicity: Hepatic failure, sometimes fatal, has been reported in patients.
56
Q

indications pregabalin

A

1) Neuropathic pain associated with diabetic neuropathy
2) Postherpetic neuralgia
3) Adjunctive therapy for partial seizures
4) Fibromyalgia

57
Q

pregabalin is a schedule V drug and a pregnancy category C

A

remember that

58
Q

indications gabapentin

A

mostly anti-seizure med, but for pain:

1) post-herpetic neuralgia
2) diabetic neuropathy
3) prophylaxis for migraine
4) treatment of fibromyalgia
5) restless legs syndrome

59
Q

gabapentin is a pregnancy category C

A

remember that

60
Q

MOA tramadol

A

codeine analog

weak mu agonist

works primarily by blocking NE and 5-HT reuptake

61
Q

indications tramadol

A

moderate to moderately severe pain

more effective than codeine, less effective than morphine

62
Q

side effects tramadol

A

sedation, dizziness, headache, dry mouth, constipation

Serious side effects:
1) can cause seizures in epileptics

2) can precipitate hypertensive crisis if combined with MAO
3) serotonin syndrome if combined with SSRI, TCA, triptans, MAO, etc

63
Q

MOA tapentadol

A

moderate to strong opioid agonist

similar to oxycodone at mu receptors

blocks re-uptake of NE

64
Q

compare adverse effects of tapentadol w/ traditional opioids

A

tapentadol causes less constipation

65
Q

indications tapentadol

A

reserved for patients who are not effectively treated with other non-opioids and opioids

66
Q

MOA ketamine

A

NDMA antagonist

67
Q

indications ketamine

A
  • starting and maintaining anesthesia

- post-operative pain

68
Q

side effects ketamine

A
  • psychological reactions (agitation, confusion, hallucinations)
  • elevates blood pressure
69
Q

MOA dexmedetomidine

A

alpha 2 adrenergic agonist

70
Q

indications dexmedetomine

A

analgesia and sedation

  • Short-term sedation in critically ill patients who were intubated and are undergoing mechanical ventilation
  • Sedation prior to/during surgical procedures
71
Q

how is dexmedetomine administered

A

IV

72
Q

adverse effects dexmedetomidine

A
  • hypotension, bradycardia
  • nausea
  • dry mouth
  • transient
  • hypertension
  • agitation
  • constipation
  • respiratory depression
73
Q

dexmedetomidine is a pregnancy category C

A

remember that

74
Q

MOA clonidine

A

alpha 2 adrenergic agonist

blocks transmission of pain signals from periphery to brain

75
Q

indications clonidine

A

1) used for HTN
2) relief of severe pain
3) treating severe cancer pain in those not treated effectively by an opioid alone

76
Q

how is clonidine administered

A

continuous infusion through epidural catheter

77
Q

adverse effects clonidine

A

enhances hypotensive and depressant effects of other drugs

78
Q

MOA ziconotide

A

selective antagonist at N-type voltage sensitive calcium channels on nociceptive afferent neurons in dorsal horn of spinal cord

blocks transmission of pain signals from periphery to brain

79
Q

indications ziconotide

A

only for chronic severe pain in those for whom intrathecal administration is warranted and when refractory to other treatments

80
Q

adverse effects ziconotide

A

Confusion, memory impairment, speech impairment, hallucinations, etc.

also causes muscle injury (from elevated serum creatinine kinase levels)

**enhances depressant effects of other drugs

*generally resolve within 2 weeks of drug discontinuation

81
Q

ziconotide is a pregnancy category C

A

remember that

82
Q

MOA and indications capsaicin

A

stimulation of TRPV1 (heat reeptor) and desensitizes and/or depletes substance P

nociceptive and neuropathic pain

83
Q

MOA camphor and menthol (ICY HOT)

A

camphor: TRPV1 receptors
menthol: stimulates TRPM8 (cold)

84
Q

MOA pentazocine

A

prototype for the agonist-antagonist opioids used to treat mild to moderate pain

kappa opioid receptor agonist and mu opioid receptor antagonist

85
Q

indications pentazocine

A

analgesia and sedation

86
Q

MOA butorphanol

A

prototype for the agonist-antagonist opioids used to treat mild to moderate pain

87
Q

contraindications butorphanol

A

pts w/ history of MI

b/c it increases cardiac work

88
Q

how is butorphanol administered

A

usually given IM or IV, but nasal spray is opioid tx of choice for migraine

89
Q

indications buprenorphine

A

used primarily to treat addicts, but also to treat mild to moderate pain

90
Q

adverse effects buprenorphine

A

prolongs QT interval

can cause spasm of sphincter of oddi –> poses risk for pts w/ pancreatitis or biliary dz

91
Q

indications ergotamine

A

drug of choice for terminating ongoing migraine attack

92
Q

MOA ergotamine

A

blocks inflammation associated w/ trigeminal vascular system and suppresses release of CGRP

93
Q

adverse effects ergotamine

A
  • nausea vomiting
  • weakness in legs, myalgia, numbness and tingling of fingers and toes
  • angina-like pain and tachycardia or bradycardia
94
Q

overdose of ergotamine causes _____

A

ergotism

  • constriction of peripheral arteries cause extremities to become cold, pale and numb with gangrene a possibility
95
Q

ergotamine is a pregnancy category X

A

remember that

96
Q

indications dihydroergotamine

A

drug of choice for terminating ongoing migraine attack

97
Q

MOA dihydroergotamine

A

blocks inflammation associated w/ trigeminal vascular system and suppresses release of CGRP

98
Q

compare ergotamine and dihydroergotamine

A

both drug of choice for terminating ongoing migraine attack

dihydroergotamine does not cause N/V, has no physical dependence, and minimal peripheral vasoconstriction, BUT diarrhea is prominent

99
Q

MOA sumatriptan

A

5-HT agonist

100
Q

indications sumatripan

A

first line drug for terminating migraine attacks

constricts intracranial blood vessels and suppresses release of CGRP

relieves HA and nausea, neck pain, photophobia, and phonophobia

101
Q

sumatriptan should not be combined with what other drugs

A

ergot alkaloids, MAOIs, SSRIs, SNRIs

Ahmed Neuro 2 Depression (16 decks)

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