Pharmacology & Medical Pain Management Flashcards
What is an INCORRECT strategy in treating incident pain?
Increasing the dose of long acting pain medications (can worsen side effects)
What are the most common side effects of NSAIDs? Who should NOT get them?
1) RENAL DYSFUNCTION RENAL DYSFUNCTION- do not use in patients with renal disease, CHF, elderly, cirrhosis, on diuretics, dehydrated
2) GIB- ulceration, bleeding (as common as renal)
3) Cognitive changes in elderly- confusion, memory changes, irritability (less common than renal issues)
4) Reduced control over HTN (less common)
What drugs should be AVOIDED in patients on tamoxifen therapy? Why?
Antidepressants (Paxil, Fluoxetine, Duloxetine, Buproprion) (all inhibit CYP2D6)
Tamoxifen is (a prodrug) converted to its active metabolites via CYP2D6
No difference in mortality BUT may have more adverse cancer outcomes (response rate, symptom prevalence)
SAFEST are venlafaxine, sertraline, citalopram
Who should receive a baseline EKG when starting methadone? (7) When should this be repeated?
Patients with
1) electrolyte abnormalities
2) impaired liver function
3) structural heart disease
4) genetic predisposition
5) use of other drugs that may prolong the QTc
6) any prior EKG with a QTc greater than 450 ms
7) history suggestive of ventricular arrhythmia
Baseline is when STARTING drug or done in 3 months prior
Must REPEAT when total daily dose of methadone is 30-40 mg/day
What are the constellation of symptoms associated with opioid induced bowel dysfunction? (6)
1) constipation
2) abdominal pain
3) nausea/vomiting
4) anorexia
5) dry mouth/xerostomia
6) GERD.
Two major enzymes responsible for opioid metabolism??
CYP3A4 (fentanyl, methadone, oxycodone, tramadol) and CYP2D6 (hydrocodone, methadone, morphine, oxycodone, tramadol)
Inhibitors of CYP3A4? Fentanyl, methadone, oxycodone, tramadol, codeine (3 main classes)
1) Amiodarone, diltiazem, verapamil
2) Ciprofloxacin, Clarithromycin, Erythromycin
3) ketoconazole, voriconazole, FLUCONAZOLE, itraconazole,
Inducers of CYP3A4? As in what makes Fentanyl, methadone, oxycodone, tramadol, codeine LESS effective
1) Carbamazepine, oxcarbazepine
2) Phenobarbital, phenytoin
3) Rifampin
4) Dexamethasone
5) St. John’s wort
Inhibitors of CYP2D6? (4 drug ‘types’). Codeine, hydrocodone, methadone, MORPHINE, oxycodone, tramadol
1) Amiodarone
2) Buproprion, duloxetine
3) Citalopram, Lexapro, Fluoxetine, Sertraline, Paxil
4) Haldol, Chlorpromazine
5) Reglan
6) Hydroxyzine, Benadryl, Doxepin
Active metabolite of codeine? Or hydrocodone?
Codeine–> Morphine
Hydrocodone–> Hydromorphone by CYP2D6
What is mechanism of memantine? Side effects?
NMDA antagonist
Side effects
- Dizziness
- Agitation
- Hallucinations
- Confusion
- Constipation
- Headache
- Elevated BP
What is the mechanism for donepezil? Rivastigmine? Galantamine?
Anticholinesterase inhibitors
Donepezil: Can cause INSOMNIA
All can cause BRADYCARDIA
SLUDGE symptoms (Cholinergic Crisis)
Salivation
Lacrimation
Urination
Diarrhea/diaphoresis
GI upset (nausea)
Emesis
2 random cardiac drugs that also have anticholinergic side effects and can lead to anticholinergic toxicity?
1) Digoxin
2) Furosemide
Opioids that can cause serotonin syndrome?
Other common HPM drugs that can cause serotonin syndrome?
Tramadol, fentanyl, methadone, tapentadol, meperidine
Ondansteron, metoclopramide, trazodone
SSRI with anticholinergic properties?
Paxil
Avoid in elderly!
What are signs and symptoms of androgen insufficiency? Workup? TX?
Fatigue, depression, anxiety, sexual side effects
Can occur WEEKS after starting chronic opioids but reverses within DAYS if opioids are stopped
FSH, LH, total T
Treat with T replacement
What metabolite is responsible for OIH?
Morphine 3-glucuronide is a neurostimulant
that can lead to agitated delirium, myoclonus, hyperalgesia, and even seizures. Morphine and hydromorphone are
the most common culprits. Morphine 6-glucuronide is a metabolite that is active on the mu-opioid receptor, and
thus is not a major player in terms of inducing agitated neurotoxicity.
Only 2 indications for Dronabinol?
AIDS cachexia
Chemo induced nausea/vomiting
Treatment for oral thrush?
Clotrimazole Troches (if can tolerate 5 times per day dosing)
Otherwise–> fluconazole
Treatment for esophageal candidiasis?
Systemic fluconazole
3 ways opioids cause nausea?
1) Direct stimulation of CTZ
2) Reduces GI motility (early satiety, bloating)
3) Triggers vestibular apparatus
Common side effects of cisplatin?(8)
nausea
vomiting
anorexia
myelosuppression
renal failure
paresthesias
rash
elevated LFTs.
Common side effects of docetaxel?(7)
myelosuppression
alopecia
elevated LFTs
anorexia,
dyspnea
cough
myalgias
Common side effects of doxorubicin? (6)
alopecia
congestive heart failure
facial flushing,
nausea/vomiting
anorexia
mucositis
Dexamethasone causes WHAT palliative care symptom? What other two classes of meds also cause this same symptom?
Hiccups!!
Opioids and benzos can also cause hiccups!
Patient stem has patient with Lewy Body Dementia or Parkinson’s…. what drug choice do you NOT choose?
ANYTHING that is anti-dopaminergic
- Haldol or other typical AP
- Reglan
- Chlorpromazine, Prochlorperazine etc
What are the 4A’s of Pain?
The Four A’s include: analgesia (pain relief); activities of daily living (functional status); adverse effects; aberrant drug-taking behaviors.
4 specific concerns for tramadol? What is it LESS likely to do compared to morphine?
1) Seizures
2) Serotonin syndrome
3) Hypoglycemia
4) Suicide risk (especially if on SSRI, hx of addiction or MH issues)
LESS likely to lead to addiction or respiratory depression compared to morphine
Never give trazodone for patient if stem has hx of WHAT issues?
Severe MDD/suicide
EtOH abuse
What are the 3 types of pain fibers?
C fibers: SLOW conducting
- Small, unmyelinated fibers
-Transmit dull, poorly localized, diffuse, burning, aching pain
- Sensitive to: mechanical, thermal, CHEMICAL stimuli
A delta fibers: FAST conducting
-Large, MYELINATED fibers
-Transmit well-localized, SHARP pain
-Sensitive only to mechanical and thermal stimuli
A beta fibers: Rapidly conducting, transmit TOUCH sensation
-Mainly concerned with NON NOXIOUS input
-Involved in ALLODYNIA–> touch perceived as pain
5 phases of pain transmission? Which is NOT responsive to drugs?
1) Transduction
2) Conduction
3) Transmission
4) Perception
5) Modulation
PERCEPTION! Only thing that helps is CBT, relaxation, music therapy etc
