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Ortho > Pharm Review > Flashcards

Pharm Review Flashcards

1
Q

Most preferred NSAIDs for pts?

A
  • Naproxen and ibuprofen

- most can be dosed w/ loading dose if needed

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2
Q

Diff classes of NSAIDs?

A
  • Salicylate (acetylated)
  • Salicylate (nonacetylated)
  • Propionic acids
  • acetic acids
  • oxicams
  • fenamates
  • nonacidic
  • selective COx 2 inhibitors
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3
Q

MOA of NSAIDs?

A
  • inhibit Cox which impairs transformation of: arachadonic acid - to prostaglandins - prostacyclin and thromboxanes
  • Cox 1 enzymes: regulates normal cellular processes (gastric cycytoprotection, vascular homeostasis, platelet aggregation, kidney fxn)
  • Cox 2: expression of this is increased during states of inflammation, effects of Cox-2 inhibition on inflammation isn’t completely understood
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4
Q

Adverse effects of NSAIDs?

A
  • GI
  • Renal
  • CV
  • liver
  • pulm
  • heme
  • malignancy
  • derm
  • healing of MSK injuries
  • up to 12% of hosp admissions for adverse drug runs are NSAID related
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5
Q

Renal adverse rxns of NSAID use?

A
  • renal vasoconstriction, acute renal failure, HTN, hyperkalemia, hyponatremia, edema, increased risk of Renal cell cancer
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6
Q

Hepatic adverse rxns of NSAIDs?

A
  • can cause elevation of liver transaminases
  • actual NSAID assoc liver injury is rare
  • may be disease specific (more common in SLE and RA)
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7
Q

Pulm adverse rxns of NSAIDs?

A
  • adverse events seem to be more likely to be related to nonselective COX 1/2 inhibitors and less likely w/ selective COX 2 inhibition
  • bronchospasm
  • pulm infiltrates w/ eosinophilia
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8
Q

Heme adverse rxns of NSAIDs?

A
  • neutropenia
  • antiplatelet effects due to inhibition of COX1:
    for most NSAIDs - platelet fxn normalizes w/in 3 days of d/c of drug (24 hrs for ibuprofen)
  • but still need to continue ASA for cardioprotection if using NSAID therapy
  • interaction w/ warfarin, may increase INR
  • higher risk of bleeding w/ anticoag. use
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9
Q

CNS adverse effects of NSAIDs?

A
  • Aseptic meningitis
  • tinnitus: usually w/ salicylates but can occur w/ all NSAIDs, usually reversible upon d/c
  • ## psychosis and cog impairment: more common w/ indomethacin, elderly
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10
Q

Skin adverse effects of NSAIDs?

A
  • drug rash or pseudoporphyria (blistering w/ sun exposure)
  • blistering skin lesions that may be potentially life threatening:
    TENS
    SJS
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11
Q

NSAIDs effects on fx healing?

A
  • may cause non-union (approx 1%)
  • may want to avoid NSAIDs for up to 90 days post fx
  • data isn’t clear, more studies needed
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12
Q

NSAID CIs mnemonic?

A
  • Nursing or preg
  • Serious bleeding
  • Allergy/asthma/angioedema
  • Impaired renal fxn
  • Drug (anticoag)
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13
Q

NSAIDs: salicylates?

A
  • Acetylated
  • ASA only one in this group
  • diff from other classes by irreversible platelet inhibition for the life of the platelet
  • don’t use to tx pain, just use for its CV protective effects
  • other NSAIDs may dampen it’s anti-platelet effects
  • usually continue chronic aspirin use if adding another NSAID for pain management
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14
Q

Propionic acids?

A
  • Naproxen

- Ibuprofen

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15
Q

Naproxen pros, formulations and dosages?

A
  • available OTC
  • long acting
  • less CV risk compared to others
  • 2 formulations: naproxen base and naproxen sodium
  • dose: 200 mg naproxen base = 220 mg naproxen sodium (has quicker onset of action than base)
  • max daily dose: Day 1- 1250 mg naproxen base, subsequent daily doses shouldnt exceed 1000 mg naproxen base (or 1100 mg naproxen sodium)
  • take q 12 hrs
  • good choice for tx of acute or chronic pain if NSAID is indicated
  • may give loading dose of 500 mg naproxen base or 550 mg naproxen sodium
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16
Q

Use of ibuprofen, dosing?

A
  • available OTC
  • short duration of effect
  • alt to naproxen
  • max dose: 2400 mg/day (up to 3200 mg on day 1 if loading dose used)
  • may give loading dose up to 1600 mg
  • usual analgesic dose is 400 mg q 4-6 hrs
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17
Q

Acetic acids class?

A
  • IV ketorolac (toradol)

- Indomethacin (Indocin)

18
Q

Use of Ketorolac (toradol)?

A
  • optional loading dose: 30 mg (usually just need 15 mg)
  • adjust dose based on age and wt
  • tx of moderate to severe postop pain
  • risk of gastropathy when used more than 5 days
  • not for oral use
  • don’t use for chronic pain or inflammation
  • make sure pts are well hydrated and w/o sig kidney disease
19
Q

Use of Indomethacin (indocin)?

A
  • optional loading dose 75 mg
  • comes in an immediate release and extended release
  • max dose per day: 150 mg
  • used for tx of acute gout and pericarditis mainly**
  • not for chronic daily use: higher risk of GI bleed, adverse effects
  • may be assoc w/ aplastic anemia
20
Q

Oxicams class?

A
  • meloxicam (mobic)

- prioxicam (feldene)

21
Q

Use of Meloxicam?

A
  • long duration of effect (qday dosing): 7.5-15 mg qday
  • slow onset of action
  • max daily dose: 15 mg
  • relatively COX2 selective at lower total dose of 7.5 mg
22
Q

Use of Piroxicam (feldene)?

A
  • an option for tx of chronic pain and inflammation poorly responsive to other NSAIDs
  • daily dose of more than 20 mg increase risk of serious GI complications
  • usual daily dose is 10-20 mg once daily
23
Q

Use of celecoxib (celebrex)?

A
  • selective COX-2 inhibitor
  • optional loading dose of 400 mg
  • max daily: 400 mg
  • usual dose is 100 mg BID or 200 mg daily
  • no effect on platelet fxn
  • decreased GI toxicity
  • dose related renal and CV effects
  • sulfa allergy - CI to celebrex use
24
Q

How do you judge who needs narcotics?

A
  • sig soft tissue swelling or ecchymosis suggests sig injury
  • pain at rest
  • night pain
  • pain uncontrolled by NSAIDs or APAP
  • anyone who has had surgery
  • sometimes may just need narcotics at night
25
Q

Narcotic pain relief used in ortho pain?

A
  • codeine
  • hydrocodone
  • oxycodone
26
Q

Use of Codeine?

A
  • considered weak opioid
  • for mild-moderate pain
  • schedule III
  • met. to morphine: if not properly metabolized it isn’t effective
  • if metabolized too quickly = initial overdose, shorter duration of action, more SEs
  • 5-10% of pts have genetic variation fo metabolism and may have only limited or no benefit from codeine
27
Q

Use of hydrocodone?

A
  • lorcet, lortab, norco, vicodin
  • Schedule III
  • for moderate to severe pain
  • onset of action: 10-20 min
  • duration: 4-8 hrs
  • in combo w/ acetaminophen
28
Q

Use of oxycodone?

A
  • percocet, roxicet, endocet
  • schedule II
  • moderate to moderately severe pain
  • onset of action: 10-30 min
  • in combo w/ APAP
  • avoid long acting combos for acute pain (MS contin)
29
Q

Use of Naloxone?

A
  • reverses resp depression, sedation and analgesia
  • 0.04mg-0.08 mg IV push q 1 min x 2
  • may need to repeat dosing as half life is short
30
Q

Extended release and long acting opioid analgesics - when should these never be used?

A
  • NEVER for acute pain

- NEVER in narcotic naive pt

31
Q

Toxicities of all opioids in general?

A
  • sedation and resp depression: drugs that act on CNS potentiate effects, EToH, sedative-hypnotics, TCAs, BZDs, MAOIs
  • constipation: worse w/ sustained release morphine compared to fentanyl patch, stool softners alone are not enough (need laxative)
  • decreased effectiveness of diuretics: induce release of ADH and counteracts effect of diuretics
  • QT prolong
32
Q

When may opioid drug levels decrease or increase?

A
  • if used concomitantly w/ cytochrome P450 inhibitors or inducers
  • inhibitors: buproprion, fluoxetine, paroxetine, cimetidine, acyclovir, duloxetine, fluoroquinolones, ketoconazole, PPIs, verapamil, diltiazem, grapefruit juice
  • inducers: carbamazepine, isoniazid, tobacco, rifampin, St. John’s wort
33
Q

Extended relief and long acting opioid analgesics?

A
  • morphine sulfate ER: MS contin, kadian, Embeda, Avinza
  • buprenorphine transdermal: butrans
  • methadone: dolophine
  • fentanyl transdermal: duragesic
  • hydromorphone: Exalgo
34
Q

Rules for transdermal admin?

A
  • never cut or tear patch
  • heat exposure can increase release and absorption of transdermal opioid analgesics
  • application: chest, side of waist, upper arm, avoid hairy areas but if not clip the hair, rotate sites, wash site w/ water only
35
Q

Use of Tramadol? MOA? Metabolism? Caution?

A
  • not a controlled substance (schedule IV), but has high potential for physical and psych dependence
  • works at mu receptors and also inhibits NE and serotonin
  • effective for relief of neuropathic pain
  • improved fxnl outcomes in pts w/ fibromyalgia
  • may be no more effective than NSAIDs or nortryptyline for chronic pain
  • extensively metabolized in the liver
  • use w/ caution in elderly and w/ renal insufficiency
36
Q

Skeletal muscle relaxants used?

A
  • cylcobenzaprine (flexeril)
  • tizanadine (zanaflex)
  • metaxalone (skelaxin)
  • diazepam (Valium)
37
Q

Use of muscle relaxants?

A
  • short course of therapy only
  • most benefit is w/in 1st 1-2 wks of therapy
  • very sedating w/ anticholinergic SEs
  • not generally for long term use unless neuromuscular problems that cause spasticity
38
Q

Risk of abuse of muscle relaxants?

A
  • diazepam (valium) and carisoprodol (soma) should be used only briefly (few days)
  • high potential for abuse
39
Q

Use of muscle relaxants and NSAIDs?

A
  • may have synergistic effect for tx of acute low back pain

- pts more likely to improve when used in combo

40
Q

What offers the best pain relief?

A
  • NSAIDs or APAP in combo w/ narcotics
41
Q

How do you avoid bowel obstruction if tx w/ narcotics?

A
  • tx w/ stool softeners and gentle stimulant laxatives prn

Ortho (24 decks)

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