PHRM845-FINAL EXAM Flashcards
Non-malignant pain
What is pain?
Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
-Hard to assess
Why does pain matter?
-Number 1 reason pts seek care
-30% of Americans have chronic pain
-Interferes with QOL and productivity
-Annual cost in US exceeds 500 billion dollars
-Opioid epidemic: need for increased safety due to elevated opioid related deaths–prescribing opioid pain meds and pts become addicted
Role of pharmacists
-Assess pain
-Recommend OTC
-Refer pts
-Recommend initial analgesic prescription to providers
-Educate pts on analgesic tx
-Evaluate safe and effective use (abuse, SE, etc.)
-Adjust med tx based on response
-Track opioid use (INSPECT in IN)
-Med recs
Questions to subjectively assess a pt’s pain
“PQRSTU” mnemonic
P: Palliative or precipitating (What makes it better/worse?)
Q: Quality of pain
R: Region of pain location
S: Severity (pain assessment instruments)
T: Time related nature of pain (How long have they been in pain for? Is it worse at certain times of the day?
U: Impact of pain on yoU
What have you tried to control the pain?
Objective info to assess pain
-Behavioral changes (moaning, groaning, screaming in pain)
-Physiological changes
~Dilated pupils (mydriasis)
~Paleness (pallor)
~Sweating (diaphoresis)
~Tachycardia
~Tachypnea (Fast respiratory rate)
Types of pain intensity scales to assess pain
-Verbal
-Numeric
-Visual
-Wong-baker
What is the verbal pain scale?
-No pain
-Mild pain
-Mod pain
-Severe pain
-Worst possible pain
What is the visual analog scale?
On a line with no pain to worst pain possible, where would you put yourself?
What is a numeric pain intensity scale?
-Most widely used
-Scale of 1-10, where do you rate your pain?
What is the wong-baker assessment?
Emoji faces for people to rate their pain
-Some kids may be sad about something else and may mix it up with the pain rating
How long does pain last for it to be acute vs chronic?
Acute: < 3 months
Chronic: > 3 months
Types of chronic pain
-Nociceptive (Tissue damage)
-Neuropathic (nerve)
-Mixed (tissue and nerve)
Guidelines for tx of pain
-CDC
-PADIS
-NICE
-AAFP
**NOT 1 guideline for pain
Goals of tx
-Correct underlying cause of pain if possible
-Minimize pain and sx from pain/injury (may not be possible to be pain-free; discuss this with pt; want pt’s pain a 3 or less)
-Improve QOL and AODL
-Limit pharmacotherapy SE
Selecting an analgesic: We must first look at patient factors and medication factors
Patient factors:
-Hepatic/renal function
-PMH
-Previous analgesic tx
-Routes of administration (some kids can’t swallow tablets and some pt cannot swallow)
-Type of pain (nociceptive vs neuropathic)
-Severity of pain
Medication factors:
-Allergies/cross reactions
-Cost
-Drug-drug interactions
-DOA/dosing frequency
-Potency
-Route of administration
-SE
Non-pharm tx
-Correct underlying cause (main focus—surgery/avoidance)
-Exercise
-Acupuncture
-Massage
-Heat or Ice
-Physical manipulation (chiropractor)
**Can be a combination with analgesic
Step 1 of the tx approach
Non-opioid +/- adjuvant analgesic
Step 2 of the tx approach
Opioid for mild/moderate pain + non-opioid +/- adjuvant analgesic
Step 3 of the tx approach
Opioid for moderate/severe pain + non-opioid /- adjuvant analgesic
Non-opioid analgesic
-Acetaminophen
-Non-steroidal anti-inflammatory drugs (NSAIDs)
Adjuvant analgesic
-Gabapentinoids
-SNRI
-TCA
-Muscle relaxant
-Antiepileptics
-Topical agents
Acetaminophen (Tylenol)
-Dosage forms
-Analgesic and antipyretic
-Available formulations
~Tablet (regular strength: 325 mg; extra strength: 500 mg; arthritis: 650 mg ER)
~Capsule
~Chewable tablet (80 or 160 mg)
~Liquid/gel
~IV solution (if throwing up or bowel obstruction)
~Suppository
Acetaminophen recommended dosing
Adults: 325-1000 mg PO Q4-6H PRN (max dose <3-4 g/day)
~In liver disease, the max is 2 g/day
Peds: 10-15 mg/kg PO Q4H PRN (max dose 75 mg/kg/day or <3-4 g/day)
SE of acetaminophen
-Hepatotoxicity (acute liver failure most likely with more than 10 g dose)–most common cause of acute liver failure in the US
Clinical pearls of acetaminophen
-Gold standard for osteoarthritis due to fewer SE in geriatric pts than NSAIDs
-Educate pts about max daily doses, including combo products
-Injection is expensive (often restricted use–>ex is surgery)
NSAIDs
-SE and clinical pearls
-Analgesic, antipyretic, and anti-inflammatory
-SE
~GI bleed (BBW)–breaks down stomach lining
~Nephrotoxicity
~Fluid retention: hold onto a bit of Na+ too
~Increase CV events (BBW)
-Clinical pearls
~Take with food
~Caution use in geriatric pts due to increased SE (Beer’s list)
~Avoid systemic NSAIDs in pts with cardiac hx (HF or MI)–can use topical NSAIDs instead (would not absorb much systemically)
~Avoid in severe liver disease or CKD
Aspirin
-Available formulations
-Clinical pearls
-Chewable tablet
-Tablet
-EC tablet
-Capsule
-ER capsule
-Suppository
Clinical pearls:
-Avoid using for pain in pts taking blood thinners or antiplatelets
-Some formulations available OTC
Aspirin dosing
Adults: 325-1000 mg PO Q4-6H PRN (max 4 g/day)
Pediatrics: Anyone under 18 y/o should avoid ASA due to Reye’s syndrome
Reye’s syndrome
-Rare but serious condition that causes swelling in brain and liver
-Associated with children/teens using ASA when they have viral infections, like the flu or chickenpox with or without a fever
**Not always sure if child is immunocompromised so just avoid ASA use
Ibuprofen (Advil, Motrin)
-Available formulations
-Clinical pearls
-Capsule
-Tablet (regular strength=200 mg)
-Chewable tablet
-Suspension
-IV solution
Clinical pearls: some formulations are available OTC
Recommended dosing of ibuprofen
Adults: 200-800 mg PO Q6-8H PRN (max: 3200 mg/day)
Pediatrics (> 6 months): 5-10 mg/kg PO Q4-6H PRN (max 40 mg/kg/day or 2400 mg, whichever is less)
Diclofenac (Valtaren)
-Available formulations
-Clinical pearls
-Capsule
-Tablet
-IV solution
-Suppository
-Topical gel (1%)
-Topical solution
-Ophthalmic solution
-Patch
Clinical Pearls:
-Minimal systemic SE with topical gel
-Some formulations available OTC
-Use if pt has CKD
Recommended dosing for diclofenac
Adults: 50 mg PO Q8H or 2-4 g applied topically QID
Naproxen (Naprosyn, Aleve)
-Available formulations
-Clinical Pearls
-Capsule
-Tablet
-DR/ER tablet
-Suspension
Clinical pearls:
-Some formulations available OTC
Recommended dosing for naproxen
Adults: 220-500 mg PO Q6-12H (Max: 1000 mg/day)
Ketorolac (Toradol)
-Available formulations
-Clinical pearls
-Tablet
-IV/IM solution
-Nasal spray
-Ophthalmic solution
Clinical pearls:
-Maximum duration is 5 days (parenteral + oral)
~Increased risk of GI bleed when used longer
-Oral dosing is intended as a continuation of IM or IV therapy ***Only recommend oral if pt is started on IV
Recommended dosing of Ketorolac
Adults: 15-30 mg IV/IV q6h prn or 10 mg PO q6h prn
Pediatrics: 0.5 mg/kg/dose IM/IV q6h prn
Celecoxib (Celebrex)
-Available formulations
-Clinical pearls
-Capsule
-Oral solution (less common)
Clinical pearls:
-COX-2 selective (less GI toxicity & less GI bleeding)
-Caution in pts with heart, liver, and kidney disease
